Clinical Quality Assurance Specialist- SF Center- PT Day

Sanford Health•Sioux Falls, SD

23d•$24 - $39

About The Position

Shall be a representative of nursing administration and shall perform necessary delegation and coordination of clinical, operational and managerial activities to accomplish the objectives of the assigned area(s) of nursing. Will incorporate responsibilities related to the quality risk and risk score adjustment programs. Assist with the quality improvement review and audit related to potential quality risk issues and adverse events as part of the quality risk program. Will complete chart reviews, documentation of findings, referral for medical director review and required reporting. Will perform healthcare effectiveness data and information set (HEDIS) record reviews and assist with clinical questions related to chart reviews. Must work collaboratively with internal and external departments to ensure all aspects of workflow are completed. Will review the risk score adjustment information for medical chart record requests and potential medical chart review. Manage the chart review process by reviewing the record request list, collaborating with information technology (IT) for file accuracy, coordinating the record requests with providers or vendors and collaborating with the chart review vendor, if applicable. Review the medical visit file to determine individuals requiring outreach to coordinate medical services. Assist members in the coordination of appointments for services. Required to complete tracking documentation of medical record requests, chart reviews and medical visit appointments to ensure status is current. Must be analytical and have critical thinking, problem solving and decision making skills. Must be organized and able to multi-task. Must be proficient in computer software such as Word and Excel. May included duties as a liaison for accrediting or governing agencies for services such as sleep medicine.

Requirements

Must be analytical and have critical thinking, problem solving and decision making skills
Must be organized and able to multi-task
Must be proficient in computer software such as Word and Excel
Graduate from a nationally accredited nursing program preferred, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
Minimum of five years of nursing experience.
Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state.
Obtains and subsequently maintains required department specific competencies and certifications.

Nice To Haves

Bachelor's degree in nursing preferred.
Experience and knowledge of accreditation and regulatory agency standards preferred.
Quality, medical coding, and/or risk adjustment experience is preferred.
Certified Professional in Healthcare Quality (CPHQ) or medical coding certification preferred, but not required.
Quality improvement/assurance personnel with nursing backgrounds can maintain their license without seeking additional hours based on role’s responsibilities.

Responsibilities

Delegation and coordination of clinical, operational and managerial activities
Incorporate responsibilities related to the quality risk and risk score adjustment programs
Assist with the quality improvement review and audit related to potential quality risk issues and adverse events as part of the quality risk program
Complete chart reviews, documentation of findings, referral for medical director review and required reporting
Perform healthcare effectiveness data and information set (HEDIS) record reviews and assist with clinical questions related to chart reviews
Work collaboratively with internal and external departments to ensure all aspects of workflow are completed
Review the risk score adjustment information for medical chart record requests and potential medical chart review
Manage the chart review process by reviewing the record request list, collaborating with information technology (IT) for file accuracy, coordinating the record requests with providers or vendors and collaborating with the chart review vendor, if applicable
Review the medical visit file to determine individuals requiring outreach to coordinate medical services
Assist members in the coordination of appointments for services
Complete tracking documentation of medical record requests, chart reviews and medical visit appointments to ensure status is current