Quality Health Specialist
Location: Janesville, Wisconsin
Description: Mercyhealth is hiring Quality Health Specialist right now, this vacancy will be located in Wisconsin. More details about this vacancy opportunity please read the description below. POSITION TITLE: Quality Health Specialist 1
JOB SUMMARY
Performs detailed duties relating to and in support of the utilization management processes and case management processes. Knows and understands the processes and timelines for all lines of business. This includes MercyCare products (HMO, SELECT, PLUS (WI and IL), EPO, MVP, BadgerCare, and Senior); all products where MercyCare is participating as a third party administrator for medical management (EHC EPO); Mercy Health System products where MercyCare provides medical management (MPA) and other products as they are introduced. Has an understanding of covered benefits, non-covered services and level of benefit as they apply to the appropriate line of business. Follows the appropriate process or policy and procedure for pre-authorization, concurrent and post-service request for office, outpatient, inpatient, or pharmacological requests and complete within critical timelines. Is able to process assigned service requests independently and assign the appropriate length of stay within the critical timelines.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Prioritize â€" must be able to prioritize daily work to meet critical timelines.
Receipt of requests â€" must be able to take a fax request or verbal request and make determinations of appropriate form or transfer to an appropriate form for review process. Must be able to use the computer to verify member eligibility, determine dual coverage or other primary or secondary insurance payors, establish if there are overlapping requests or duplicate requests.
Review of request â€" Must be able to determine if request is valid or invalid and understand appropriate process for either. Must be able to determine if notes should be requested for continued process of request.
Data entering â€" must be able to enter accurate authorizations for pending reviews, approvals and denials in MHS Power system. Knows and understands additional databases for entry if applicable for request. Identifies what requests may need additional sheets for entry, such as baby sheets for newborn entries.
Completion of review process â€" must be able to complete appropriate letters according to standard, nurse direction or medical director direction. Provide proof reading and make appropriate suggestions. Able to complete authorizations accurately and appropriate benefit level for each provider.
Aware of department policies for processes and understands they are in place to meet NCQA Standards or to determine medical necessity. Understands that some processes and policies are in place to achieve accreditation and improve HEDIS compliance rates.
Must be able to coordinate and manage multiple phone lines that are both direct lines and message lines. Able to identify the need of the caller to provide assistance or transfer to the most appropriate person, such as Utilization Management Nurse, Case Management Nurse, Customer Service Representative, Provider Relations Representative, or Midwest Security Customer Service.
Effective verbal communication skills to communicate with co-workers, facility utilization review / case management staff, physician offices, and members as needed. Ability to converse in a respectful and informative manner.
Strong written communication skills and documentation skills, able to meet requirements set forth in policies.
Insures that all activities are internal and external customer focused, well planned, organized and controlled to assure the cost effectiveness for utilization management and case management.
Assists in the staff support activities for special projects or tasks as assigned by the Medical Director or Team Leader.
Check Up after Delivery (CUAD) entry and letters
Hyperlipedemia â€" projects and mailings (including database printing, entry and mail merging)
Filing â€" Making up multi-line files, data base entry, member based filing, pre-cert based binder filing, Mercy Hospital based binder filing, and others as needed or determined
Other projects as may be developed or determined by the Medical Director or Team Leader
Survey follow-up calls
Participates in department meetings or on committees as assigned.
Participates in developing and updating policy and procedures for the Quality Health Management Policy and Procedure Manual that relate to the job functions of this position.
AGE OF PATIENT POPULATION
All
COMPETENCIES
To perform the job successfully, an individual should demonstrate the following competencies:
Quality - Follows policies and procedures; Adapts to changes in the environment; Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance.
Service - Responds promptly to requests for service and assistance; Meets commitments and critical deadlines; Abides by MHS confidentiality and security agreement; Shows respect and sensitivity for cultural differences.
Partnering - Supports organization's goal and values; Exhibits objectivity and openness to other's views; Gives and welcomes feedback; Contributes to building a positive team spirit; Generates suggestions for improving work.
Cost - Conserves organization resources.
EDUCATION, TRAINING, & EXPERIENCE
High school graduate or equivalent
Previous experience in healthcare or health insurance preferred.
Medical terminology preferred.
Computer knowledge and experience
ADDITIONAL REQUIREMENTS
Passing the Driver’s License Check and/or Credit Check (for those positions requiring).
Passing the WI Caregiver Background Check and/or IL Health Care Workers Background Check.
Must be able to follow written/oral instructions.
OTHER SKILLS AND ABILITIES
To perform this job successfully, an individual should have:
Computer skills: Knowledge of Database software, Internet software, Spreadsheet software, Word Processing software, and Microsoft Outlook.
Language skills: Structure sentences and serve as a proofreader. Knowledge of medical terminology.
Mathematical Skills: Add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
Reasoning Ability: Solve practical problems. Interpret a variety of instructions furnished in written, oral, diagram or schedule form.
Self-starter who is highly motivated and can function independently or as a team member.
Able to prioritize daily work. Proven ability to successfully work within a team environment.
Acts as an external and internal spokesperson for the department and supports system wide efforts and resolutions.
WORK ENVIRONMENT
The noise level in the work environment is usually quiet to moderate.
Occupational Exposure is Category C which means no employees in the specified job classifications have occupational exposure
INFORMATION ACCESS
Partner may access patient care information needed to perform their job duties
Partner may access financial data
Partner may access strategic and planning data
WORK CONTACT GROUP
MercyCare Health Plans, facility utilization management, case management, admission, or billing departments, physicians, nurses, ancillary services, continuing health care providers, members or families.
SPECIAL PHYSICAL DEMANDS
The Special Physical Demands are considered Essential Job Function of the position with or without accommodations.
While performing the duties of this job, the employee is frequently required to sit. Specific vision abilities required by this job include close vision, peripheral vision and ability to adjust focus. Manual dexterity for operating office equipment and completing mass mailings. Some bending and pulling associated with filing.
LEVEL OF SUPERVION/SUPERVISES
This job has no supervisory responsibilities.
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If you were eligible to this vacancy, please email us your resume, with salary requirements and a resume to Mercyhealth.
Interested on this vacancy, just click on the Apply button, you will be redirected to the official website
Apply Quality Health Specialist Here
This vacancy will be opened on: Mon, 29 Jan 2018 23:55:42 GMT
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