PRINCIPLE RESPONSIBILITIES :
Responsible for provider facility site review audits, specifically, but not limited to the qualitative and quantitative content of the medical record and the compliance with quality of care standards.
Responsible for delegated oversight monitoring of contracted provider organizations. Primary responsibilities include the following : Principle responsibilities include : noto "" sans "" noto "" sans "" * noto "" sans "" Conducts, participates and / or leads facility site review audits, using the DHS / Alliance Site Survey Tool, to assure compliance with local, federal, and state standards.
Supervises and provides training for site review staff.Uses clinical experience and judgment to assess completeness and appropriateness of provider medical record entries, including history and physical examinations, initial health assessments, progress notes, provider response to lab and diagnostic study results and consultation reports.
Uses clinical experience and judgment when using a medical record audit tool to measure provider compliance with medical record standards pertaining to legibility, identification, signatures / authentication, mid-level protocols (if applicable), and content, screens for potential and actual quality issues and sentinel events.
Prepares complete and accurate reports on facility site reviews and delegates audit results on a timely basis.Conducts, participates, and / or leads the delegated oversight and monitoring of contracted provider organizations, using the Alliance Delegated Audit Tool to evaluate compliance with contractual agreements.
Identifies trends, patterns and opportunities for improvement seen over the course of provider facility site review, medical record review and delegated oversight.
Communicates findings with Alliance and provider staff, and makes recommendations, as needed, for quality improvement activities and monitoring.
Follows policies and procedures regarding reporting of quality issues and assists in the preparation of reports and summaries for peer committees, as appropriate.
Available to Grievance Coordinator and Quality Leadership to assess quality issues with a clinical perspective.Educates providers and office staff regarding quality improvement processes and corrective action interventions, to come into compliance with Alliance, Federal, State, and NCQA standards.
Participates in quality monitoring audits, projects, and other activities including Potential Quality Issue reviews to meet regulatory and contractual requirements.
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Identifies trends, patterns and opportunities for improvement seen over the course of provider facility site review, medical record review and delegated oversight. Participates in quality monitoring audits, projects, and other activities including Potential Quality Issue reviews to meet regulatory a...
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