Quality & Patient Specialist I

Teche Health, A Federally Qualified Health Center, per Section 330 of the Public Health Service Act, is currently seeking qualified applicants for the Quality & Patient Specialist I position in Franklin, Louisiana. 

JOB SUMMARY:

The Quality & Patient Specialist I is an integral part of the Quality & Clinical Risk Management Team. This position supports the development and maintenance of quality improvement efforts to achieve improved clinical outcomes and mitigate clinical risks. This position serves as the preceptor for staff responsible for Medication Prior Authorizations. This position performs heavy chart monitoring and auditing of medical records. Assists with maintaining organizational adherence to Joint Commission standards. They work closely with provider staff, clinical support staff, patients, and insurance carriers to ensure timely processing of documentation requests. Must have knowledge of, or the ability to develop skills to navigate internal and external patient electronic health record systems, RadMd©, and CoverMyMeds©. This position requires travel to all TAC facilities as assigned. 

  JOB DUTIES AND RESPONSIBILITIES:

• Conduct internal quality control reviews and clinical audits as assigned by CHIO or designee according to Policy and Procedure.


• Summarize findings and prepare report on findings.


• Assists CHIO or designee in implementing key quality strategies, which may include initiation and management of provider and patient interventions, preparation of quality improvement compliance surveys/audits, performance measurement activities related to HEDIS, UDS and other quality metrics.


• Assist with preparation for clinical audit requests of external stakeholders according to Policy and Procedure.


• Assist in maintaining ongoing tracking and appropriate documentation on all audit requests and audit findings.


• Assist in promoting clinical staff awareness of audit finding to improve clinical outcomes and patient safety.


• Ensure complete and accurate patient demographic and current insurance information.


• Assists in data collection, data entry and generation of reports in support of QI initiatives including but not limited to access and availability audits, HEDIS abstraction, EMR reviews, patient satisfaction studies, UDS audits and reports, additional internal and MCO/ ACO requests as assigned.


• Support the development of quality improvement performance audit function processes and tools.


• Contact insurance companies to ensure prior approval requirements are met as appropriate. Present necessary medical information such as history, diagnosis, and prognosis.


• Assist CHIO or designee with preparation and ongoing compliance to Joint Commission standards including conducting tracer activities as assigned.


• Establish and maintain relationships with internal and external stakeholders.


• Maintain documentation of pending and completed audits.


• Track findings of audits; maintain documentation of status for received medical records requests, including consult notes, following audits.


• Conduct chart audits to ensure up-to-date documentation of all patient information.


• Determine the need for pharmaceutical prior authorizations as assigned by supervisor.
  
  
  

• Process pharmaceutical prior authorizations (PA) using the CoverMyMeds© database, when applicable, or calling by communicating directly with insurance carriers.


• Track pending PAs for determination of status.


• Ensure up-to-date documentation of all patient’s prior authorization request.


• Communicate with the provider regarding determination status, required documentation needed according to insurance guidelines.


• Answer phone calls from patients, pharmacies, and insurance carriers using exemplary customer service skills.


• Review structured clinical data matching it against specific medical terms and diagnoses.


• Assemble information concerning patient's clinical background and prior approval needs, provider appropriate clinical information for further review.


• Receive requests for records from insurance carriers specific to PA and ensure all requested records are sent in a timely manner and in compliance with HIP AA regulations.


• Maintain patient confidentiality as defined by state, federal, and TAC requirements.


• Greet patients, caregivers, and staff in a timely and pleasant manner.


• Project a congenial and sensitive attitude toward patients, caregivers, and staff.


• Exhibit a willingness to resolve problems and inefficiencies.


• Provide consistent, timely and friendly service to both external and internal customers.


• Actively support departmental and organizational strategic plans.


• Actively support departmental and organizational quality assurance and performance improvement initiatives.


• Performs other duties as assigned which are consistent with the position and in compliance with the organizations policy and procedure.


• Performs other duties as assigned by Assistant Director of Quality & Clinical Risk Mgt, CHIO & CEO which are consistent with the position and in compliance with the organizations policy and procedure.
  

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each duty described above satisfactorily. The following requirements are representative of the knowledge, skill and/or ability required for this job.

Education/Experience:

• High School Diploma or equivalent and a minimum of 5 years in healthcare quality improvement / performance improvement.
  


• Knowledge and experience in outpatient clinic setting and insurance prior authorization processes preferred.


• Experience with electronic health records, CoverMyMeds© and RadMed© applications preferred.
  

Communication Ability: 

• Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals.


• Must have interpersonal skills.


• Ability to write routine reports and correspondences.


• Ability to speak effectively with provider and clinical support staff, insurance carriers, and patients.

Math Ability: 

• Ability to add and subtract two-digit numbers and to multiply and divide with 10's and 100's.


• Ability to perform these operations using units of American money and weight measurement, volume and distance.
  

Reasoning Ability:

• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.


• Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.


• Ability to work reliably and with professionalism in a high-volume, high-demand medical environment.

Computer Skills:

• Proficiency in Microsoft Word, Microsoft Excel, and email.


• Prefer skills in using EHR software.


• Prefer skills in using referral EHR software, CoverMyMeds© and RadMD© applications.

Professional Skills:

• High level of confidentiality required.


• Ability to work independently and within a team.

Benefits Package:

• Medical, Vision and Dental Health Insurance


• Accidental Insurance


• Critical Illness Insurance


• Cancer Insurance


• Hospital Indemnity Insurance


• Long Term Benefits


• Short Term Benefits


• Free Life Insurance


• 401K Plan Benefits 


• Paid Vacation


• Paid Sick Time


• Set Schedule
  


• National Health Service Corps Site


• 11 paid holidays


• Family-Friendly Work Environment


• Eligible for Student Loan Forgiveness through Federal and State Programs

Eligibility Requirements:

• All employees must meet eligibility standards in order to be considered for the position applying for. Internal applicants must be with be with the organization for at least one year, with no disciplinary actions on file. If you have not been with the organization for a year, approval from your direct supervisor will be needed.

              **Due to CMS Mandate all applicants must be fully vaccinated prior to onboarding with Teche Health with the exception of an approved Medical or Religious Exemption.**