Quality Coordinator

Job Description

Job Description

POSITION SUMMARY

The Quality Coordinator is responsible for analyzing Medicare data, including but not limited to, authorizations, grievances, appeals, case management, network adequacy and composition of membership data to identify potential errors, non-compliance issues, and areas for improvement in patient care, ensuring adherence to accreditation and regulatory standards. Collaborate with internal teams to implement quality improvement initiatives, all while maintaining patient privacy and confidentiality.

Position is onsite Monday-Friday.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Review and analyze data across various areas, including claims, authorizations, grievances, appeals, case management, network adequacy, membership composition, and other related fields.
• Assist with QOC investigation, QIC Prep, monitoring and auditing.
• Supports with NCQA renewal survey.
• Collects reporting for measurement and benchmarking of performance measures in relation to best practices for NCQA, CMS, and internal business objectives.
• Ensures data is accurate, reliable, and reported timely.
• Collects performance indicator reports and benchmark narratives for review by Quality Director for performance improvement recommendations.
• Assists with monitoring quality performance, outcomes and / or metrics to make recommendations for targeted process improvement projects.
• Prepares overviews and interpretation of reports; and following up on assigned action items for various projects, meetings, and committees.
• Assists with training departmental Quality program requirements.
• Assists with problem analysis for strategic planning initiatives.
• Solves data integrity issues as they arise, and monitor the addition of new data, analytics and reporting systems.
• Assist with interpretation and translation of data for senior management for use in meaningful decision making, and strategic planning purposes.
• Assists with audits and preparation of audit responses.
• Collects supporting documentation to support review of Quality-of-Care concern investigations.

QUALIFICATIONS AND EDUCATION

WORKING CONDITIONS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This work requires the following physical activities : climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours / days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and / or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or listen. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

PERFORMANCE MEASUREMENTS

This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.