What are the responsibilities and job description for the Quality Reviewer (Onsite/Remote) position at MetaStar, Inc.?
Job Title: Quality Reviewer
Department: External Quality Review
Pay Type: Salaried Exempt
Workforce Classification: Full time (40 hours/week), 1.0 FTE
Location: Onsite in Madison, WI; Hybrid, or Remote (residing in the state of WI)
Job Summary
The requirements listed below are representative of the knowledge, skills, and/or abilities required to successfully perform this job at the minimum level. Additional requirements are listed as preferred.
The requirements and conditions described below are representative of the general environment the individual is exposed to on a day-to-day basis while performing this job.
Department: External Quality Review
Pay Type: Salaried Exempt
Workforce Classification: Full time (40 hours/week), 1.0 FTE
Location: Onsite in Madison, WI; Hybrid, or Remote (residing in the state of WI)
Job Summary
- Reports directly to: Long Term Care Project Manager or Project Manager Medicaid Managed Care
- Direct reports to this position: None
- Other individuals or MetaStar staff with whom the person works on a regular basis:
- External Quality Review (EQR) Department staff
- Information Technology Department staff
- Wisconsin Department of Health Services (DHS) staff
- Managed Care Organization (MCO) staff and members
- Special Managed Care Organizations
- County Health and Human Services staff and affiliated sub-contractors operating the Wisconsin Children’s Long Term Support Waivers and Birth to 3 programs
- Include, Respect, I Self direct (IRIS) Consultant Agencies and Fiscal Employment Agent staff and participant
- Hospital Staff
- WISe Agencies
- Essential duties and responsibilities:
- Conduct external quality review activities for Wisconsin’s long term care programs as directed by DHS.
- External quality review is the analysis and evaluation of aggregated information on quality, timeliness, and access to services furnished by these programs and is conducted according to protocols published by the Center for Medicare and Medicaid Services (CMS).
- Review activities include but are not limited to those described below:
- Coordination and Continuity of Care review activities (record reviews)
- Access multiple electronic health record systems and read member/participant records to evaluate compliance with certain federal and state requirements as well as industry standards. Priorities are placed on confirming that member/participant health and safety is assured. Effectively communicate results orally and in writing.
- Compliance with Federal and State standards for Medicaid managed care programs
- Understand and apply federal and state requirements. Read and analyze documentation submitted by an MCO. Facilitate discussions with a wide variety of staff to determine and evaluate the effectiveness of implementation of expectations throughout an MCO. Determine level of compliance and effectively communicate results orally and in writing.
- Validation of Performance Improvement Projects (PIPs)
- Read and analyze written reports regarding improvement of clinical and non-clinical processes or outcomes of care, associated documentation, and data from MCOs. Facilitate discussions to confirm understanding. Determine if the project was designed, conducted, and reported in a methodologically sound manner. Effectively communicate results orally and in writing.
- Read written proposals from MCOs designed to achieve improvements of clinical or non-clinical processes or outcomes of care. Provide technical assistance orally and in writing and make recommendations about approval status.
- Validation of Performance Measures
- Conduct reviews according to review protocols to abstract and verify performance measurement data from a variety of sources, but not limited to medical records, encounter data, MCO and DHS systems data.
- Collaborate with MCO and agency representatives to obtain missing and clarify existing data.
- Summarize and compile findings using standardized forms and templates for reports.
- Review activities associated with FC, FCP, PACE, IRIS waiver programs’ member appeals and grievances.
- Triage and talk with members, participants, and/or legal representatives to identify and understand concerns. Access multiple electronic health record systems and read member/participant records. Communicate with all parties via telephone and work to mediate a resolution. Document all activities in a database and communicate outcomes in writing.
- Develop and implements review activities independently and in collaboration with others in EQR and including DHS staff. Review activities must align with CMS protocols, as needed.
- Create review activity and aggregate reports according to timelines and formats developed in collaboration with DHS.
- Participate in inter-rater reliability testing in order to achieve standards of accuracy and consistency in applying review guidelines for specific review activities.
- Review the work of others and work collaboratively with team members through ongoing feedback to ensure that work meets internal and external quality standards.
- Collaborate with EQR team members to improve existing systems/processes/standard operating procedures (SOPs) and to develop new ones.
- All other duties as assigned
The requirements listed below are representative of the knowledge, skills, and/or abilities required to successfully perform this job at the minimum level. Additional requirements are listed as preferred.
- Bachelor’s degree in Nursing or health or human services-related field will be considered (social work, rehabilitation psychology, mental health, substance abuse services, or other allied health professions). Licensure/certification in the State of Wisconsin, as appropriate.
- Minimum of 5-8 years’ experience in clinical practice with experience in working with specific target populations, based on the current needs of the External Quality Review department including, but not limited to: frail elders, developmentally disabled, and/or physically disabled adults and/or children; adults and children with severe emotional, behavioral, mental health and substance use disorders. Experience in coordination of acute and primary and/or long-term care services, consumer education related to disease management, education and coordination of services for children and families of children with developmental and/or physical disabilities and severe emotional disturbances.
- Long term care experience required and managed care experience preferred, including knowledge of managed care delivery systems, organizations and financing.
- Knowledge of continuous quality improvement, process improvement and Lean principles.
- Experience in performance measurement, quality assessment, and quality improvement projects or initiatives including:
- Application of sound and effective information gathering, analysis and decision making strategies
- Assessment of the significance of information with regard to standards and regulations
- Production of clear, focused and professional written documentation.
- Knowledge of the conditions, current philosophies, nationally recognized approaches, and community alternatives for the adult and children’s populations being served under the managed health and long-term care waiver programs; knowledge of Medicaid eligibility and benefit policies, data systems and processes.
- Knowledge and proficiency in using electronic medical and health records systems
- Proficiency in Microsoft Office applications
- Ability to work well independently and within a team structure.
- Self-motivated, critical thinker with a strong desire to learn and apply existing and new skills.
- Excellent communication (oral and written) and small and large group facilitation skills
- Travel required to locations throughout Wisconsin to conduct onsite review.
- Valid Driver’s License or ability and means to travel as required.
- Contributes to MetaStar’s Mission, Vision, Values
- Uses Quality Improvement Concepts in Daily Practice
- Provides Excellent Customer Service
- Shows Initiative
The requirements and conditions described below are representative of the general environment the individual is exposed to on a day-to-day basis while performing this job.
- Manual Dexterity: Ability to operate computer and telephone
- Physical Effort: Ability to sit or stand for five-to-eight hours per day (depending on scheduled FTE); occasionally lifting up to 15 pounds.
- Equipment Used: Computer and telephone
- Working Conditions: Traditional office environment; required to work on a computer five-to-eight hours per day (depending on scheduled FTE)
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