Job Ref: 57909
Category: Quality Assurance
Department: QUALITY MANAGEMENT
Location: 160 Water St. #3, New York, NY
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $68,000.00
Salary Range: $74,160.00 - $74,160.00
MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
The primary function of the In-Field Coordinator is to provide education and training to physicians, staff and pharmacists at their practice locations and in the community to ensure compliance with a focus on HEDIS, QARR and Medicare Advantage Star quality measures. Responsible for participating in initiatives across a broad array of clinical measures and health improvement activities. Completes member outreach and education as needed to ensure members receive appropriate services. In addition, this position will provide support and training to physicians on proper coding and medical record documentation practices to support improvement in quality metrics. The position may also facilitate referrals to Case Management to assist with transition of care issues and Customer Service as needed to address member concerns.
The position will be field based and require travel within the MetroPlus Health Plan service area.
- Maintain proficiency in MetroPlus Health Plan Quality programs, HEDIS/QARR measures, Hybrid/Administrative manuals, MetroPlus Health Plan systems, Provider Electronic Medical Record systems and utilize this information to set and meet goals.
- Appropriately utilize provider educational tools to provide support and training to physicians, provider staff and pharmacists to ensure compliance with Clinical Practice Guidelines, Preventive Health guidelines and quality improvement activities to improve the delivery of quality health care and service to MetroPlus members.
- Monitor provider-specific HEDIS report cards. With the guidance, identify areas of concern and address with office management and/or hospital contacts to initiate improvement.
- Monitor provider/facility progress on monthly basis; prepare and distribute monthly member gap in care reports and partner with onsite Medical Management staff to coordinate closure of gaps in care through:
- EMR system review of member gap lists to identify and share data collection opportunities, coding errors, documentation shortfalls, appointment timing issues.
- Outreach to MetroPlus members by face-to-face encounters, telephonically and via other communication venues to provide education on how to access services, the importance of health maintenance, preventive health visits and maintaining a relationship with their PCP.
- Provide or arrange for health education for members with various diseases such as but not limited to Asthma, Diabetes, Hypertension, Hypercholesterolemia, Obesity and Heart Disease to prevent readmission and/or utilizing the emergency room inappropriately.
- Identify noncompliant members that require appointments and work with the providers to ensure timely member appointments are obtained. Or, directly set up appointments for MetroPlus health education initiatives and/or other needed screenings/tests i.e. lab work, eye, dental exams, etc. via the hospital's scheduling system.
- Refer potential candidates to on-site facility health education programs or disease management collaborative as appropriate.
- Document all interventions and telephone encounters with providers, members, and vendors in the appropriate system in accordance with established documentation standards for MetroPlus Health Plan to ensure integrity of member services provided over the continuum of care and over time.
- Participate in facility and community events or telephonically outreach to provide MetroPlus members education on how to access services, the importance of health maintenance, preventive health visits and maintaining a relationship with their PCP
- Complete on-site provider visits and/or meetings with admin/claim management on a regular basis to conduct education sessions regarding appropriate coding practices and medical record documentation practices. Reviews site coding practices to look for improvement opportunities
- Maintain knowledge of medical record review and EMR systems. Facilitate retrieval of medical record documentation and work with provider group(s) to retrieve electronic data that supports HEDIS/QARR. Records findings of patient encounters to include patient identifiers, relevant information and results.
- May work with community provider offices to facilitate request and review of charts in support of HEDIS & QARR annually.
- Other duties as assigned by Manager.
- Bachelor’s Degree preferred
- Clinical background: Health Educator, RN, LPN, or LCSW, Foreign Medical Graduate (FMG) preferred but not required
- Experience with medical record review working on HEDIS/QARR in a managed care or health plan setting.
- Prior experience in Quality Improvement in a health care and/or Managed Care setting strongly preferred.
- An equivalent combination of training, educational background and experience in related fields and educational disciplines.
- Ability to proficiently read and interpret medical records required.
- Knowledge of HEDIS specifications required.
- Knowledge of ICD-10 and CPT codes preferred.
- Knowledge of Microsoft Office applications including Word, Excel, PowerPoint, Access and Visio.
- Ability to travel within the MetroPlus service area.
- Experience with relationship management.
- Ability to work in a team setting.
- Integrity and Trust
- Customer Focus
- Functional/Technical/Analytical Skills
- Written/Oral Communications