PRINCIPLE RESPONSIBILITIES: Responsible for provider facility site review audits, specifically, but not limited to the qualitative and quantitative content of the medical record and the compliance with quality of care standards. Responsible for delegated oversight monitoring of contracted provider organizations. Primary responsibilities include the following:
Principle responsibilities include:
Conducts, participates and/or leads facility site review audits, using the DHS/Alliance Site Survey Tool, to assure compliance with local, federal, and state standards. Supervises and provides training for site review staff. Uses clinical experience and judgment to assess completeness and appropriateness of provider medical record entries, including history and physical examinations, initial health assessments, progress notes, provider response to lab and diagnostic study results and consultation reports. Uses clinical experience and judgment when using a medical record audit tool to measure provider compliance with medical record standards pertaining to legibility, identification, signatures/authentication, mid-level protocols (if applicable), and content, screens for potential and actual quality issues and sentinel events. Prepares complete and accurate reports on facility site reviews and delegates audit results on a timely basis. Conducts, participates, and/or leads the delegated oversight and monitoring of contracted provider organizations, using the Alliance Delegated Audit Tool to evaluate compliance with contractual agreements. Identifies trends, patterns and opportunities for improvement seen over the course of provider facility site review, medical record review and delegated oversight. Communicates findings with Alliance and provider staff, and makes recommendations, as needed, for quality improvement activities and monitoring. Follows policies and procedures regarding reporting of quality issues and assists in the preparation of reports and summaries for peer committees, as appropriate. Available to Grievance Coordinator and Quality Leadership to assess quality issues with a clinical perspective. Educates providers and office staff regarding quality improvement processes and corrective action interventions, to come into compliance with Alliance, Federal, State, and NCQA standards. Participates in quality monitoring audits, projects, and other activities including Potential Quality Issue reviews to meet regulatory and contractual requirements. Other duties as assigned. ESSENTIAL FUNCTIONS OF THE JOB: 66% Facility Site Review (scheduled and random)
2% Delegated Monitoring Activities
20% Compilation and production of reports
05% Consultation and review of complaints, grievances, and other quality issues
2% Data entry
5% Other Duties in support of Clinical Review
PHYSICAL REQUIREMENTS: Constant and close visual work at desk or computer. Constant sitting and working at desk. Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. Frequent walking and standing. Frequent lifting of folders, files, binders, and other objects weighing between 0 and 30 lb. Frequent driving of automobile. Frequent travel between offices for meetings Possible travel by aircraft. Number of Employees Direct Supervision: 0
MINIMUM QUALIFICATIONS: EDUCATION OR TRAINING EQUIVALENT TO: Current, unrestricted Registered Nursing (RN) license in the state of California Bachelor of Science in Nursing or related field or equivalent experience. MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE: Three to five years' experience in managed care, hospital, or similar setting SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE): Direct patient care in hospital, provider's office, clinic, other care setting Knowledge of NCQA, Title 22, Title 10 and other regulations governing provider participation in managed care Experience in utilization management systems Experience with provider facility site review Experience abstracting or screening medical records Familiarity with PC word processing, spreadsheet, and database Excellent verbal and written communication skills Employees who interact with members of the public may be required to be tested for Tuberculosis and fully vaccinated against COVID-19 and influenza. Successful candidates for those positions/ classifications may be required to submit proof of vaccination against influenza and/or COVID-19, a negative Tuberculosis test, or request an exemption for qualifying medical or religious reasons during the onboarding process. Candidates should not present proof of vaccination until instructed to do so by the Human Resources department.
SALARY RANGE $105,853.04-$158,779.55 Annually The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.