QA Specialist-64541703

JOB SUMMARY

The Quality Improvement Specialist provides oversight of operational procedures, outreach and compliance. The Quality Improvement Specialist implements quality improvement systems, data analysis, and programming processes.

ESSENTIAL JOB FUNCTIONS: List all essential job duties. (To perform this job successfully, an individual must be able to perform each essential duty listed satisfactorily with or without a reasonable accommodation. Reasonable accommodations may be made to enable qualified individuals with a disability to perform the essential duties unless this causes undue hardship to the agency.)

• Pull Revenue Cycle Management reports to monitor enrollments, entitlements, and collections to maximize revenue.
•  Collect, track, and analyze program data (KPIs, outcomes, productivity).
• Reviews a weekly billing report detailing denials, inconsistencies with documentation and service billed, and clients with no billing for the month.
• Ensure that billing is submitted in a timely manner with the appropriate rate code
• Ensure clean claims are prepared and work with Finance to ensure all billing denials are addressed by identifying Medicaid eligibility issues, incorrect CIN, DOB, etc. and needed corrections are accurately reflected in the corresponding EHR.
• Navigate EHR health information systems such MAPP, ePaces and PSYCKES to enhance outreach and engagement strategy planning and data informed care.
• Translates data into actionable information for direct care staff and leadership to facilitate data informed care and performance improvement.
• Assist with revenue cycle management, including billing submission, tracking and reconciliation of unpaid claims
• Conducts data analysis and reporting to support program operations and to meet reporting requirements of funders/payers. Ensure timely submission of reports to appropriate oversight/funding organizations.
•  Defines policy, procedures and program standards to ensure internal program compliance with federal, state, city and agency requirements.
• Communicate effectively with referral sources, Managed Care Plans, OMH, DOHMH, DOH, and other providers regarding referral, enrollment, and authorization for services/ level of service determination.
• Review internal and external audits to maintain OMH and OASAS regulation.
• Cultivates effective relationships with internal ICL programs (Clinics, Housing, Residential treatment and more) to ensure adequate service delivery.
• Develop workflows to map program processes for referral enrollment, billing, reporting and quality improvement measures. Design and maintain performance management system to monitor and improve productivity, compliance and quality.
• Assist with specialty projects, outreach efforts, community events, member engagement and presentation to increase the census of programs as it relates to revenue improvement.
• Quality wellness checks via telehealth.
• May be assigned other tasks and duties reasonable related to job responsibilities.

ESSENTIAL KNOWLEDGE, SKILLS AND ABILITIES:

• Committed to the promotion of the ICL values and goals.
• Proficient in Excel formulas and functions (v lookup, pivot tables, etc).
• Knowledge of agency policies, program policies, procedures and functions.
• Team player able to work efficiently multi-disciplinary team.
• Ability to provide administrative support to program staff.
• Excellent oral and written communication skills.
• Skilled at data manipulation and visualization.
•  Ability to design and maintain electronic filing system.
• Ability to design for the collection of information.
• Ability to prioritize and follow through on multiple tasks simultaneously
• Organized, independent and personable.

QUALIFICATIONS AND EXPERIENCE

Bachelor’s degree and 2 years of clinical and database experience. Must have experience using multiple databases, and proficient in Microsoft Word, and Excel.