This position audits and monitors patient charts for compliance based on the organization policies and procedures, managed care, UDS, PCMH, and HEDIS requirements. Employees in this position analyze, interpret, and verify medical information based on documentation in electronic health records. This employee act as a resource for the primary care clinics and interact with providers and management to provide a high level of information as requested in a timely and accurate manner.
Performs electronic health records chart reviews (Practice Management and Electronic Health Records – adult medical, pediatrics, women health, behavioral health and dental charts) and completes appropriate chart audit forms. Prepares chart review summaries for individual provider monthly reports as well as chart review summaries for QI meetings as requested.
Presents chart audit findings to work group meetings, committees and as requested. Performs rapid cycle improvements monitoring, documents and presents results.
Performs targeted chart reviews (on-boarding, after-hours calls, clinics consents. Etc.) as requested by Clinics Directors.
Participates in creating action plans, suggest improvements and best practices. Focus on adhering to company and regulatory policies and guidelines.
Assist as needed for ongoing clinics educational programs regarding proper documentation as required by insurance companies and audit agencies. Suggests chart template adjustments and improvements for easier and more accurate documentation.
Performs care specific HEDIS/UDS audits which involves looking at different types of care (diabetes, childhood immunizations, HTN, sealants etc.)
Responsible for clinic process reviews such as closing referral loops, providers timely signing of documents, labs, and signing encounters. Performs Retrospective Review of medical records for medical necessity/severity of illness/intensity of service to authorize claims reimbursement. Monitors unnecessary test ordering.
Contributes to department payment/claims integrity by verifying that certain diagnoses and procedures match the medical codes that were listed in the billing.
Ensures timely issue escalation to manager and proactive consultation with the Clinical and operational teams.
Able to work with various software programs related to both Business office operations and Clinical Charting. Be conversant with Clinical and Business departments.
Attends staff and continuing education meetings.
Conducts ongoing research of regulatory review criteria, CPT, ICD-10, and related health care standards.
Functions as a team member and provides information to other departments as appropriate.
Emergency duty may be required of the incumbent that includes working in Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or disasters, man-made or natural.
Associate’s Degree in Nursing required.
Three (3) years utilization review required. Working knowledge of Microsoft Word and Outlook required. CPT, ICD-10 Codes qualifications preferred.
State of Florida Registered Nurse license required.