Position Number:171-5124 Open Date:8/24/2009 Close Date:Open until filled Program:Health Coverage Department:Managed Care Location:West Palm Beach, FL
The Health Care District of Palm Beach County is a special taxing district that is an equal opportunity employer of approximately 1000 employees. Established in 1988, the Health Care District's mission is to maximize the health and well-being of Palm BeachCounty residents by addressing health care needs and planning for the access and delivery of health services. For more information and additional position openings at the Health Care District of Palm Beach County, visit www.hcdpbc.org.
This position will be responsible for participating in the evaluation of the quality of care provided to managed care members.Employees in this position perform studies, audits, chart reviews, surveys and analyze data collected to implement actions to improve member care.This position includes direct involvement in committees, maintaining compliance with state, federal regulations, the managed care accreditation organization and adhering to contract responsibilities. Specific Duties include:
Preparing case summaries of quality issues for administrative review; Functions as a l
iaison for issues concerning clinical quality and operational issues; reviews complaints and grievances concerning clinical issues.
Performs on-site provider office medical records reviews with analysis of data and appropriate provider education and follow-up.
Establishes systems for confidentiality, integrity, and security of quality management records, reports, worksheets, forms, and other documentation.
Compiles and organizes data for reports as required.
Analyzes provider practice patterns as required and reports both positive and negative information to the providers credentialing files and to the appropriate committees.
Organizes statistical findings to assist in the identification of service and care trends.
Identifies member population demographics and needs with utilization data to create studies, audits and quality projects.
Complies with policies and procedures for quality and risk management functions.
Participates in on-call responsibilities as needed.
Reviews and evaluates a wide variety of data for the purpose of ensuring compliance and identifying variance to District and Healthy Palm Beaches quality management policies.
Monitors the appropriateness of care with District and Health Palm Beaches quality indicators; Also monitors the quality of health care services in terms of access, availability and delivery to District and Healthy Palm Beaches members.
Creates/designs/performs studies including focus studies, performance improvement projects utilizing HEDIS criteria when appropriate, and performance measure reviews.
Performs statistical analysis, identify goals, barriers and create interventions to improve results.
Maintains knowledge of Medicaid prepaid health contract and Vita Health contract and complies with all of the requirements including reporting requirements to state agencies and oversight organizations; Creates, updates and participates in mandated action plans as required.
Creates and researches materials for presentation, review, recommendation and approval by the Healthy Palm Beaches Committees and Board of Directors.
Represents department on appropriate committees.
Creates tools for studies, audits, and reports with input from membership data, utilization data, the committees and Board of Directors.
Valid RN license required; Minimum of an Associate's Degree in Nursing required, with Bachelor's Degree preferred.
Three (3) to five (5) years’ progressively responsible experience that includes practical experience in an acute care setting and experience in the quality/risk management functions of a managed care organization;
Also required:excellent Excel/computer skills, experience in collecting data and analysis of HEDIS Studies.
The Health Care District is an Equal Employment Opportunity Employer and maintains a Drug Free Workplace. Qualified individuals with disabilities who require an accommodation to participate in the application process should contact Human Resources. Veterans preferred.
