Quality Improvement Specialist II

Purposeof the Job

The Quality Improvement Specialist IIcontributes to the overall success of theQuality and Accreditation Department byensuring specific individual goals plansand initiativesare executed / delivered in support of the teams business strategies andobjectives.The Quality Improvement Specialist IIis responsible forperforming medical record reviews and clinical data abstraction services in support of Health New Englands clinical quality improvement operations. This valuable work provides crucial qualitative and quantitative insighttothe development and execution of clinical quality and health equity strategic plans. This position uses knowledge of paper and electronic medical records as well as medical coding guidelines HEDIS technical specifications and standards of clinical care to complete comprehensive clinical abstractionsassistsin insights analysis and translates areas of opportunity into provider office trainings. Through theseeffortswe can work to improve the healthcarequalityour community.

Accountabilities

• Champions a customer focused culture to deepen client relationships andleveragebroader Health New Englands relationshipssystemsand knowledge.

• Understand how Health New Englands culture and the CX Promise should be considered in day-to-day activities and decisions.

• Actively pursues effective and efficient operations of their respective areasin accordance withHealth New Englands Values its Code ofConductand the Associate Handbook while ensuring the adequacy adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational compliance and conduct.

• Championsahigh performanceenvironment and contributes to an inclusive work environment.

Medical Record Retrieval 10%

• Manage individual list of records for retrieval outside of direct electronic medical records

• Directly outreach to offices and coordinate record collection

• Provide provider offices effective communication on document requirements and process

• Report out to Quality Improvement Specialist II or Quality Accreditation Manager weekly on retrieval progress

• Manage one-offsubsequentmedical record requests through the pursuit process

• Process files for abstraction once received

• Maintain frequent bidirectional feedback with offices to ensure effective communication

• Work to develop effective relationships with practice staff

Medical Record Review and Abstraction50%

• Develop andmaintaina SME level of knowledge on HEDIS medical record review measures

• Usingmedical record and clinical qualityexpertise performs HEDIS clinical abstraction in both directelectronic medical record (EMR) and physical medical records to auditprovider compliance with HEDIStechnical specifications

• Reviews medical records and interprets clinical documentation for patient compliance and delivery of the standard of care during the HEDIS project Quality improvement projects and Provider incentive programs

• Serves as the lead for EMR HEDIS abstraction coding audits

• Functions as a resource for staff using NCQA certified HEDIS medical record review abstraction software

• Assistsin the on-going strategic development of Health New Englands medical record review process for all functional areas

• Perform off-regulatory-season reviews to support strategic areas of focus

Application of Medical Record Review Findings 20%

• Identifyareas of opportunity in either the clinical delivery or clinical documentation

• Develop provider office focused trainings based of the selected findings

• Communicates and coordinates reviews with physician office staff and distributes correspondence related to the review

• Gathers documentation to support annual validation audits

• Assistsin the annual development of the larger Quality Improvement and Accreditation strategy based of medical record review findings

Audit Preparation Submission and Development Strategy 20%

• Assistin general audit preparation and submission activities

• Prepare medical record review training materials and InterraterReliability testing

• Perform quality assurance audits to ensure clinical abstraction accuracy

• Manage accountability over relevant staff members to ensure all work is completed

• Ensure completeness of all necessarymedical record documentation for audit submissions

• Assistsin knowledge support of HEDISmedical record review tool