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QM Coordinator

Posting Date: 
Jul 1 2008
Hours: 
FT
Department: 
Quality
Position Summary: 
Maintains medical management programs in all areas of the health service delivery within ACCESS. Those programs include both resource utilization and quality of care monitoring for the healthcare needs of our managed care membership. It is the responsibility of this position to be the communication link between the organization’s staff at he ambulatory health centers, our primary care physicians (PCP) at those centers, Mt. Sinai Hospital Medical center (MSHMC), the contracted managed care organizations (MCO’s) with ACCESS, and all other outside vendors that have an impact on the care rendered to our managed care population. The clinical priority for the QMC is monitoring the patterns of resource utilization for efficiency and effectiveness. Appropriate and continuous monitoring will identify certain quality aspects of care for improvement. This identification is done through concurrent hospital admission review, as well as retrospective review when necessary; referral authorization review for medical necessity and appropriateness; and discharge planning at all levels of care. The QMC participates in gathering medical quality outcomes data through chart audits that are required by government agencies; audit that the MCO’s have delegated to ACCESS contractually; and studies outlined in ACCESS’s annual Quality Management (QM) Plan, for managed care, under the direction of the Medical Director. Identified areas for improvement would be taken to the Continuous Quality Improvement (CQI) Council.
Duties and Responsibilities: 

· Assists Primary Care Physician regarding provision of health services from pre-admission through post discharge periods to assure appropriate utilization of services and high quality coordinated care.
· Performs pre-admission, admission, and concurrent quality / utilization review of medical services rendered through regular review of patient records as well as consultation with providers; authorizes hospital stays according to guidelines (InterQual), and in accordance with ACCESS’s Utilization Committee criteria. Consults with the Medical Director or a designated person on the CQI council for any quality / utilization problems.
· Assures timely and appropriate discharge planning of hospitalized, nursing home, and home health care patients through consultation and coordination with physicians, ancillary service providers, and direct contact with patients and/or families as indicated.
· Maintains regular contact with appropriate hospital departments (i.e. Admitting, ER) and providers to identify and facilitate correct Primary Care Physician and transfer out-of-plan admissions to in-plan facilities.
· Recognizes quality of care issues according to acceptable clinical standards and reports issues to the QM manager and/or Medical Director as indicated.
· Interfaces with hospital affiliate speciality areas to develop and implement appropriate communication patterns, system linkages, and resource utilization to support the role of the Primary Care Physician.
· Reviews and monitors outpatient referral medical services to maintain cost effective resource utilization management.
· Provides ongoing QM & UM education to the Primary Care Physicians as well as the clinical staff.· Assists with the scheduling, preparation and organization of various CQI Committee meetings, data collection, review activities to promote ongoing education to physicians and ancillary health center staff.
· Assists in the production and distribution of routine, periodic, and special reports regarding Quality / Utilization management and cost.
· Obtains needed Provider information and submits same to the Managed Care Organizations (HMO’s) for their Credentialing Process

Requirements: 

- Current RN, LPN, ART license in the State of Illinois.
- Degree in related Health care profession preferred.
- Knowledge of ambulatory healthcare within the managed care environment required (minimum of one year).
- Diversified ambulatory healthcare clinic and /or hospital experience of three (3) years required.
- Understanding of HMO, PPO contractual agreements with hospital or ambulatory settings desired.
- Quality and Utilization Management experience preferred, especially in the ambulatory / managed care environment.
- Ability to communicate effectively and diplomatically with physicians regarding sensitive quality / utilization care issues.
- Ability to adjudicate medical claims based on the application of clinical criteria and the interpretation of MCO’s benefits of coverage