Lansing, MI, United States
Date published: 14-Feb-2018
Scope of Work: RMRA/Stars INITIATIVE
Job Title: RN Analyst/Auditor
• This project will involve training, education, review of records to encompass a variety of initiatives.
• The contractors will be reviewing medical records to help providers improve their documentation and coding. They will be educating, training and providing assistance in a variety of ways to help providers close gaps in diagnoses and treatment opportunities.
• The overarching goal for Medicare Advantage is to improve the RADV scores and STAR ratings to improve CMS reimbursement. Improving coding for all products is needed for our commercial business to appropriately risk adjust the small groups and IBU to comply with the health insurance exchange that began on 1/1/2014. The provider education component has the potential to impact health care delivery to members across all lines of business; therefore, it is expected to positively impact clinical outcomes.
The nurses and coders will be expected to participate in provider and hospital visits to educate, train and review medical records to determine the following:
1. Verify and help providers close treatment opportunities (HEDIS/Stars measures)
2. Assist and train providers on how to close diagnoses gaps
3. Train providers on the use of HEB
4. Perform clinical reviews with knowledge of body systems, anatomy and physiology.
5. Scan records as required
6. Generate summary of activity as requested
7. Develop and maintain an effective professional working relationship with providers.
8 Contact or answer questions (educate) for instate and outstate providers
In addition, contractors may be asked to work on cases involving:
1. Appropriateness of documentation for select conditions
2. Proper coding of the patients condition
3. Physician signature requirements are met (CMS guidelines)
4. Patient identification documented in the medical records.
5. Assist other departments, consultants when visiting providers to discuss a variety of HEDIS/Stars related issues not limited to high risk medications for example
6. Conduct other activities as assigned which may include other initiatives beside RMRA and Stars
7. Other duties may be assigned.
• MUST have a valid RN license!!!
• RN with HEDIS experience but will interview qualified RNs
• RNs with certified professional coding is a plus.
• R.N. licensed in Michigan
• BSN degree preferred; minimum Associate degree acceptable with a minimum 5 years professional experience, (preferably with at least 2 years in adult medicine or community health)
• Proficient in PC and MS Office skills, particularly Word and Excel
• Effective communication skills, written and verbal Working knowledge of CMS requirements
• Excellent analytical and problem solving skills
• Audit and medical chart review experience preferred
• Excellent interpersonal skills necessary to interact with all levels of personnel
• Working knowledge of HEDIS measures and NCQA requirements a plus
• Valid MI drivers license; willing to drive to provider locations and travel throughout Michigan as needed (no exceptions)
• Have a dependable vehicle every work day and be willing to travel five days a week and stay overnight when appropriate
1. Valid MI drivers license; willing to drive to various provider locations within Michigan depending on the need and depending on the other contractor locations
2. Required to travel 5 days a week depending on project
3. The greater need for a resource are in West MI, SE, Lansing, Traverse City, Flint, and any other areas within Michigan were a BCBSM office exists. However on occasion may be requested to travel outside their assigned region.
4. The BCBSM Detroit Tower location is home location to report to when not required to travel (if non-local candidate can report to other BCBSM/BCN facilities).