Quality Improvement Specialist II

Baystate Health•Springfield, MA

3d•Hybrid

About The Position

The Quality Improvement Specialist II c ontributes to the overall success of the Quality and Accreditation Department by ensuring sp ecific individual goals, plans, and initiatives are executed / delivered in support of the team’s busi ness strategies and objectives . The Quality Improvement Specialist I I is responsible for performing medical record reviews and clinical data abstraction services in support of Health New England’s clinical quality improvement operations. This valuable work provides crucial qualitative and quantitative insight to the development and execution of clinical quality and health equity strategic plans. This position uses knowledge of paper and electronic medical records as well as medical coding guidelines, HEDIS technical specifications, and standards of clinical care to complete comprehensive clinical abstractions, assists in insights analysis and translates areas of opportunity into provider office trainings. Through these efforts, we can work to improve the healthcare quality our community.

Requirements

Bachelor’s degree preferred with more than five years of clinical quality data review, medical record abstraction, risk adjustment coding or an equivalent combination of education and experience .
Certified Professional Coder (CPC-H, COC, CIC, or CRC) or Certified Coding Specialist (CCS-P or CCS)
Minimum of 2 years in coding, billing or clinical setting
Ability to read and interpret clinical documentation as detailed in the medical record for both quality of care standards and medical coding purposes
Demonstrated experience with ICD-10 Coding Guidelines and Documentation Standards, CPT, DRG and HCPCS coding systems
Experience with industry standard Electronic Medical Record systems
Knowledge of clinical data collection, analysis and data presentation methods
Skilled with Microsoft Office Suite (Word, Excel, PowerPoint, Access)
Ability to work and make decisions independently, set priorities and manage a shifting work load
Travel to provider practice to conduct medical record retrieval or onsite abstraction
Must have a valid driver’s license in good standing
Excellent verbal, written and presentation skills
Excellent organizational skills
Problem resolution skills

Nice To Haves

Experience with HEDIS technical specifications preferred

Responsibilities

Champions a customer focused culture to deepen client relationships and leverage broader Health New England’s relationships, systems and knowledge.
Understand how Health New England’s culture and the CX Promise should be considered in day-to-day activities and decisions.
Actively pursues effective and efficient operations of their respective areas in accordance with Health New England’s Values, its Code of Conduct and the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct.
Champions a high performance environment and contributes to an inclusive work environment.
Medical Record Retrieval – 10%
Manage individual list of records for retrieval outside of direct electronic medical records
Directly outreach to offices and coordinate record collection
Provide provider offices effective communication on document requirements and process
Report out to Quality Improvement Specialist II or Quality Accreditation Manager weekly on retrieval progress
Manage one-off, subsequent medical record requests through the pursuit process
Process files for abstraction once received
Maintain frequent bidirectional feedback with offices to ensure effective communication
Work to develop effective relationships with practice staff
M edical Record Review and Abstraction – 5 0%
Develop and maintain a SME level of knowledge on HEDIS medical record review measures
Using medical record and clinical quality expertise , performs HEDIS clin ical abstraction in both direct electronic medical record (EMR) and physical medical records to audit provider compliance with HEDIS technical specifications
Reviews medical records and interprets clinical documentation for patient compliance and delivery of the standard of care during the HEDIS project, Quality improvement projects, and Provider incentive programs
Serves as the lead for EMR HEDIS abstraction coding audits
Functions as a resource for staff using NCQA certified HEDIS medical record review abstraction software
Assists in the on-going strategic development of Health New England’s medical record review process for all functional areas
Perform off-regulatory-season reviews to support strategic areas of focus
Application of Me dical Record Review Findings – 2 0%
Identify areas of opportunity in either the clinical delivery or clinical documentation
Develop provider office focused trainings based of the selected findings
Communicates and coordinates reviews with physician office staff and distributes correspondence related to the review
Gathers documentation to support annual validation audits
Assists in the annual development of the larger Quality Improvement and Accreditation strategy based of medical record review findings
Audit Preparation, Submission and Development Strategy – 20%
Assist in general audit preparation and submission activities
Prepare medical record review training materials and Interrater Reliability testing
Perform quality assurance audits to ensure clinical abstraction accuracy
Manage accountability over relevant staff members to ensure all work is completed
Ensure completeness of all necessary medical record documentation for audit submissions
Assists in knowledge support of HEDIS medical record review tool