Centene - Lead Clinical Reviewer
Position Purpose: The Clinical Reviewer Team Lead Possesses advanced experience and working knowledge of QHCM Workflows and processes to be able to serve as a subject matter expert and manage workflows and record review activities of the QHCM Clinical Reviewers under the direction of the QHCM Supervisor. The positions is responsible for assisting the supervisor and the QHCM Clinical Reviewer team with the planning and assignment of work, training of staff, performing quality check activities, monitoring accuracy scores and productivity standards. The Clinical Reviewer Team Lead is responsible for providing detailed staff productivity and accuracy reports to QHCM supervisor. This position works with Provider Relations staff, Clinical Services Staff and other staff members of the QHCM team in order to assist and facilitate coordination of services related to quality of care of the member and provider related performance improvement activities. The role will also research and use best practices to achieve effective project implementation and outcomes. In collaboration with the QHCM Supervisor, provides training development of the QHCM Clinical Reviewer staff. Provides oversight of the medical record review projects and actively performs QC of the medical record reviews, identifying, tracking and reporting variation from standards of care. Provides reinforcement training sessions to QHCM Clinical Reviewers based on monthly QC and accuracy scores as needed. Creates QCI groups to enhance QHCM programs and improve primary care services accessed by members as evidenced by QARR HEDIS scores. Assists with preparation and production of training materials used by clinical review staff during the MRR project and additional documents required by auditor. Monitors Clinical Reviewers work to assure that gaps in quality of care of services are identified and referred or addressed as appropriate within QHCM and other departments. Serves as liaison between QHCM, PR and other departments involved in QARR HEDIS project and communicates with supervisor any issues to facilitate information flow and consistency of work. Assists with provider education as needed and works with FCNY internal and external customers/ contact to resolve serious issues, maintain key relationships or deal with sensitive issues. Is able to persuade, gain cooperation and acceptance of ideas or collaboration on significant projects. Anticipates problems and determines solutions to complex issues affecting department, projects or internal/external customers, making recommendations to QHCM supervisor as needed. Performs medical record reviews as needed. Performs other duties as assigned.
Education/Experience: Bachelors degree preferred; Associates degree or equivalent required. 3-5 years experience in managed care environment and QARR/ HEDIs related activities. Ability to proficiently read and interpret medical records is required. Advanced professional ability (Knowledge of NCQA standards required and knowledge of HEDIS/ QARR/ Star specifications required). Previous managerial skills preferred. Proficiency in Microsoft Office: Word, Excel, PowerPoint. Knowledge of Workday and Outlook. Proficiency in MedCapture. Effective Business Communication skills. Performance Evaluation result of Role Model is preferred for Internal Candidates. License/Certification: RN License, Licensed Physical Therapist or Foreign Medical Graduate (FMG) required.