Job DescriptionLeads the successful delivery of analyses and analytic solutions to meet business needs, interacting directly with internal and external clients and colleagues.Will act as analytic team lead and mentor for complex projects involving multiple resources and tasks in support of company objectives directly related to HEDIS.Fundamental ComponentsPerforms applied statistical research and custom analysis of integrated healthcare data, interprets results, and makes recommendations based on analytic findings to business areas.Makes recommendations about data collection methods, metrics definition and evaluation methods.Presents analytic reports to clients and stakeholders.Defines and delivers analytical solutions in support of healthcare business initiatives that drive short and long term objectives.Collaborates with internal and external partners and organizations in the design and execution of analytic studies to answer business and research questions.Designs and conducts analyses and outcome studies using healthcare claims, pharmacy, lab and supplemental HEDIS data sources, employing appropriate research designs and statistical methods.Develops, validates and executes algorithms, statistical models and reporting tools that answer applied research and business questions for internal and external clients.Develops and participates in presentations and consultations to existing and prospective constituents on information services, capabilities and performance results.Stays informed about industry trends, HEDIS, research findings and evaluation methods.Turns analysis into business/customer solutions.Creates business applications to deliver clinical or analytic solutions to constituents.Manages personal resources efficiently to achieve constituent satisfaction.Responsible for project commitments to quality, HEDIS and on-time deliverables.other responsibilities as required

Under the direction of the Director or designee, the Clinical Documentation Specialist will be responsible for the day-to-day clinical documentation chart reviews. Will work in conjunction with the Case Management department, physicians, mid-level providers and other health team members to provide for comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients. Will utilize coding and clinical expertise to identify opportunities and ensure accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes

The Point of Entry Case Management Specialist will be responsible for medical necessity review of all scheduled admissions, direct admits, and transfer requests made to the Parkview Health system for admission (excludes L&D, PBH, Ortho Hospital and Rehab/CCC). Uses established screening criteria (InterQual/CMS Inpatient List) to determine appropriate level of care of each requested hospitalization. Provides consultation to physicians and other members of the interdisciplinary healthcare team as needed prior to patient placement. Works collaboratively with Bed Management staff for appropriate bed assignment to achieve positive patient flow. Reviews payer source for potential negative financial liabilities to the patient. Ensures clinical documentation supports medical necessity criteria and meets regulatory requirements, including the admission. Facilitates or verifies appropriate admission order is present in the electronic medical record prior to bed assignment. Communicates admissions/transfers that do not meet medical necessity to the physician advisor (internal or external) and/or the Inpatient Care Transitions leadership team as needed. Actively involved in management of patients in observation status until the decision is made to admit to Inpatient or the patient discharges. Collaborates with ED case management staff to verify patients from all entry points to be reviewed prior to bed assignment.

Continuously evaluates the quality, care, treatment and outcomes of complex patient populations. Collaborates with the patient/family and caregivers to facilitate necessary resources and options for post-discharge services to support a safe discharge. Provides consultation with physicians and other members of the interdisciplinary healthcare team to facilitate patient progression to discharge. Ensures clinical documentation supports medical necessity criteria and meets regulatory requirements. Communicates the clinical status of patients related to medical necessity criteria to the physician advisor (internal or external) and/or the Inpatient Care Transitions leadership team as needed. Monitors length of stay and documents avoidable days for delay of discharge. Reviews payer source for potential negative financial liabilities to the patient.

ResponsibilitiesAnswer calls and communicate directly with claimants and providersTriage daily referrals and assign worksheets to corresponding conditions as identified by Veteran s AdministrationObtain medical history and CPT/CLIN code for specific conditionsDetermine appropriate examinations, tests and specialists required for each caseSchedule appointments for examinees including follow-upsEnsure all examinees and providers receive the necessary documentationConfirm consultative reports and diagnostic test results are received in a timely mannerSkills to be successfulPlan workload to manage priorities in a fast-paced work environmentWork efficiently and meet contract timelinesStrong customer service skills with the ability to identify and resolve problemsRequirements1 year of related healthcare experienceExperience with electronic medical scheduling and case management softwareKnowledge of medical coding and terminologyHigh School diploma, or equivalent (GED)Must be able to successfully pass national (NACI) background investigation

RoleOur nursing staff is critical to the success of our organization and our commitment to you is that we will support, develop, and celebrate the important role you play in the care of our patients by offeringUMC provides unique and rewarding opportunities for professional nurses.Student Loan RepaymentAccelerated Merit IncreasesTuition and Certification ReimbursementRN Referral BonusesClinical Ladder Program PayUMC’s Nursing Wall of Distinction Recognizes outstanding nurse staff who have received:Professional Specialty CertificationDaisy AwardGreat 100 NursesNightingale AwardJob SpecificationsEducation- Graduate of an accredited registered nursing program; Bachelor of Science in Nursing preferred.Experience- Basic Knowledge/understanding Of Oncology Therapeutic Clinical Trials Preferred.License/Certification- Required, Basic Life Support-HCP, RN licensure

Requirements:High school diploma or GED1+ year of experience in a Healthcare or Customer Service environmentProficiency in written and verbal English and exceptional customer service skills.Working knowledge of Electronic Medical Records (EMR)Individuals should be familiar with multicultural settings, display sensitivity to multicultural issues, and communicate effectively.Must be bilingual in Spanish.We Offer:Excellent team environmentState of the art facility and resourcesFull health, dental, and vision benefitsGenerous Paid Time OffLong-term stability and room for career growth