Support the risk and quality team, IPA Administrators, and the VP of Operations on Clinical Initiatives to improve patient outcomes and group quality measures in Risk Adjustment, CMS 5 Star, and the commercial and Medi-Cal programs.
Principal Duties and Responsibilities (* = essential functions):
Outreach and coordinate care for IPA members who need preventative and/or chronic care services such as mammograms, colonoscopies, uncontrolled HbA1c, uncontrolled blood pressure, etc.
Collaborate with Risk Adjustment and quality on provider education.
Maintain knowledge of clinical initiatives and risk adjustment program requirements
Maintain knowledge of 5 Star performance and risk adjustment factors for all IPAs.
Collaborate with health plans on 5 Star, commercial, and Medi-Cal gap reports.
Coordinate outreach to PCP offices on member due reports, including the No Annual Visits list.
Provide PCP offices with ongoing education on quality measures
Work with health plans to provide supplemental data
To contribute to a fair and positive work environment. *
To perform other duties as assigned.
Review, monitor, and track medical record retrieval reports to identify provider issues, including but not limited to refusals to comply with medical record requests.
Identify and follow through on potential issues affecting the Risk Adjustment project
Job Specifications (KSAs):
Requires at least two years of Risk Adjustment coder experience.
Requires knowledge of managed care processes, generally acquired through 1 or more years of experience in a Health Plan, IPA, or Medical Group environment.
Requires the ability to communicate clearly and effectively, verbally and in writing, with internal and external customers.
Requires an understanding of medical terminology, generally acquired through a relevant course or 2 years or more in a medical office setting or utilization management department.
Requires fast, accurate typing skills and proficiency in computer software, including Word and Excel
Position Performance Criteria Consistently produces accurate and timely work as it relates to departmental goals.
Demonstrates high reliability through consistent punctuality and attendance.
Competently performs position requirements with minimal supervision and direction, including taking initiative and assuming responsibility for follow-through.
Uses sound judgment in time management and prioritizing work to balance multiple tasks and meet required timeframes for all administrative activities.
Demonstrates excellent interpersonal skills as discerned through observation and team project successes.
Accurately interprets and applies departmental policies and procedures using sound judgment.
Communicates clearly, professionally, and respectfully to peers, superiors, subordinates, and clients.
Provides constructive feedback on assigned work projects.
Demonstrates overall professionalism in attitude, demeanor, and personal appearance
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