To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The Value-based Clinical Education Administrator will oversee the various Payer Gaps in Care programs and HCC coding within Northeast Medical Group, at the direction of the Value-based Program Manager. This role will take part in meetings with various insurance companies, planning of related processes and work-flows around closing quality gaps in care and HCC coding, and maintaining the necessary data for program submissions. The goal of the programs is to identify and address reported quality and HCC gaps in care in our population of patients that are determined to be high-risk based on their active diagnoses and treatments received. The measures incorporated in the Gaps in Care and HCC programs include: early detection of disease, preventative care screenings, evaluation and assessment of ongoing medical conditions and chronic disease, and medication adherence. Each Gap in Care and HCC that is addressed and tracked by the Value-based Clinical Education Administrator is submitted to the program in the various forms based on payer. The Value-based Clinical Education Administrator is responsible for abstracting all necessary clinical information and appropriate diagnoses from the EMR, educating providers on appropriate documentation of HCCs and communicating with appropriate staff when a Gap in Care or missing diagnosis is identified or additional documentation is needed for EMR compliance. Upon ensuring that a patient?s medical needs have been addressed and documented within the EMR, the Value-based Clinical Education Administrator is responsible for auditing the appropriate documentation and submitting it to the appropriate Payer Program for reimbursement. The Value-based Clinical Education Administrator will attend periodic meetings with the program staff members as well as with the Director, ACO and Value-based Program and other staff who are involved in the Managed Care programs. The position reports directly to the Value-based Manager.
Responsibilities: 1. Actively seek data from various sources such as Payers and Epic to accurately code the health status of patients. Maintain spreadsheets for various gaps in care and performance measures reimbursement programs 2. Maintain clinical knowledge and judgment needed to evaluate certain clinical measures, define appropriate HCC codes and abstract appropriate clinical information, as needed 3. Actively reference the EMR to identify patients in the reimbursement programs who have a gap in care which needs to be addressed by their provider at their next office visit. Educate providers on how to close the gaps and the appropriate documentation that will be accepted by the various payers 4. Maintain timely and structured communication to office sites regarding patient gaps in care and missing HCCs. Audit documentation to confirm accuracy. 5. Educate physicians, APRNs, Practice Managers, Nurse Care Managers and other support staff to ensure that appropriate patient needs are met and that accurate documentation of patient health status is in the EMR. 6. Communicate with payers when gap in care recommended is not clinically necessary, or the HCC is not appropriate, to remove the measure from their databases. 7. Communicate with physicians/providers when EMR shows questionable or incorrect diagnoses, to ensure that patient records are accurately maintained. This again requires clinical knowledge and decision making skills 8. Plan scheduled meetings with program leaders, participants and NEMG staff involved in the programs to keep them informed of new programs and report results from work efforts. 9. Ensure that appropriate data & documentation is located in the EMR for submission for submission, to comply with the regulations of the program. 10. Maintain timelines of the program requirements to ensure timely submissions and appropriate reimbursement. 11. Monitor program website for changes and updates to the patient population within the program. 12. Maintain dashboard statistics reporting monthly to the Director, Value-based Programs and Medical Director 13. Communicate with Quality Assurance Committee or other Committees as warranted for updates and requirements 14. Investigate programs for feasibility and play an integral role in the planning phase and work-flow institution
Degree as Registered Nurse, APRN, PA or Physician
Five or more years of clinical experience. Training and understanding of HCC coding, HEDIS and STARs.
APRN, PA, MD, DO
Clinical competency & decision making skills needed in order to guide appropriate action for patient gaps in care
Organizational skills and great attention to detail
Fluency in MS Office (Outlook, Excel, Word)
Experience in Electronic Medical Record (EMR) usage
Interpersonal skills and the ability to work effectively with a variety of staff members from clerical to Providers
Planning and development skills and the ability to project plan and outline workflows
Clear communication skills
Appropriate time management and prioritization, to ensure Managed Care projects are consistently up to date
Clinical/Medical background is necessary for accurate completion of Forms and Portals developed by payers requires occasionally lifting files or paper weighing up to 25 pounds.
Work requires manual dexterity sufficient to operate a keyboard, operate a calculator, telephone, copier, fax machine, and other such office equipment as necessary.
Work requires viewing and typing on computer screens.
Hearing must be within the normal range for constant telephone usage and vision must be correctable to 20/20.
Requires sitting for long periods of time, also stooping, bending and stretching for files and supplies
Agrees to assist other employees in duties outside of a specific job description, yet are necessary to ensure proper operation of the practice except in those areas where the employee is legally prohibited from performing these duties.
All other duties as assigned.