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Position responsible for strategically developing clinically oriented provider and community based partnerships in order to increase quality scores based on state specific quality measures. Position responsible for ongoing management of provider practice and community education on state specific quality measures. The Registered Nurse CPC will work closely to coordinate an interdisciplinary approach to increased provider performance. Provider education regarding the quality improvement program involves analysis and review of quality outcomes at the provider level, monitoring, measuring and reporting on key metrics to assist providers in meeting quality standards, state contractual requirements and pay for performance initiatives.
Candidate must be able to work in the office at 77 Water Street, New York, NY; This is also a field position going into provider’s offices; Candidate must be flexible to work in the 5 boroughs; Staten Island, Brooklyn, Queens, Manhattan, Long Island. Occasionally the candidate will work from home.
- Serves as subject matter expert (SME) for assigned Medicaid HEDIS / CMS measures, preventive health topics, leads efforts with clinical team to research and design educational materials for use in practitioner offices; serves as liaison with key vendors supporting Medicaid HEDIS / CMS Measures; consults with vendors to design and implement initiatives to innovate and then improve Medicare HEDIS / CMS Measure rates
- Identify patient care opportunities and collaborate with physician practices to ensure appropriate member appointments and care
- Coordinates and performs onsite clinical evaluations through medical record audits to determine appropriate coding and billing practices, compliance with quality metrics, compliance with service delivery and quality standards
- Investigates gaps in clinical documentation where system variation has impact on rate calculation, provides feedback to appropriate team members where issues are verified, and monitors resolution to conclusion
- Educates providers and office staff on proper clinical documentation, coding and billing practices, CMS mandated quality metrics specifications, provider profiling and pay for performance measurement and medical record review criteria, to drive quality improvement
- Documents and refers providers' non-clinical / service issues to the appropriate internal parties, to include Provider Relations and the Plan Chief Medical Officer by analyzing provider records and maintaining database
- Works with providers on standards of care, and advises providers on established clinical practice guidelines and appropriate documentation and billing consistent with CMS specific measures and technical specifications