MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

This position will report to the Vice President of Quality Management and will supervise and support the Clinical Quality Reviewer team within the Quality Management department. Clinical Quality Reviewers are assigned to high volume community providers. Their tasks include on and off-site medical record chart review, provider audits, provider education, point of care gap-in-care closure activities, education/distribution of Provider Incentive Program and targeted quality improvement initiative activities that support MetroPlusHealth performance in HEDIS, QARR, Medicare Advantage Star Ratings measures and Risk Adjustment. Additionally, this role will be responsible for the development, implementation, and updating of processes and tools that support quality review operations, i.e., audit tools, and provider educational documents, provider educational tools, training manuals and tip sheets. This position is responsible for the development and implementation of provider quality initiatives across a broad array of clinical measures and health improvement activities. Participation in the annual HEDIS and QARR hybrid medical record review project is required. This role may also participate in member outreach and education as needed to ensure members receive appropriate services.

The position is remote with a requirement to conduct field work, including in-person provider meetings, on-site chart review or collection, and/or as needed visits to the office.

• Maintain expert knowledge of medical record review and EMR systems.
• Maintain up-to-date knowledge of HEDIS, QARR and Star specifications and function as a subject expert on all HEDIS/QARR measures.
• Supervision and Support of Clinical Quality Reviewers:
  • Provider Quality Audit and Education: Distributes and tracks Audit projects. Compiles findings into target areas needing improvement and develops interventions to address gaps/deficiencies.
  • HEDIS Data Collection Support: Organizes and supports the retrieval of medical record documentation and works with provider group(s), Clinical Quality Reviewers to retrieve electronic/community data that supports HEDIS/QARR. Ensures the collection of accurate and timely file feeds and patient encounters to include patient identifiers, relevant information and results and forwards to the analytical team. Supports the design and updating of supplemental databases as identified.
  • Gap In Care Closure Activities: Monitor provider/facility progress on monthly basis; prepare and distribute monthly member gap in care reports and partner with onsite Medical Management staff to coordinate closure of gaps in care through multiple gaps in care closure activities.
  • Medical Record Review Project Supervision: Provides oversite and supervision of the Medical Record Review Project's clinical component.
  • Monitor reports from QM Operations databases that house data collected via audits and in-field data sources to ensure completeness, timeliness and consistency across all Quality Review projects and tasks.
  • Establish necessary operating and reporting tools to document activities of quality review operations by working closely with Quality Review team and Vice President of Quality Management.
  • Responsible for ensuring Provider Incentive Program Requirements and supporting documentation is circulated to providers and that Provider Report Cards are utilized to maximize incentive potential.
  • Ensure the team is well versed in, and implementing, provider facing programs (i.e., P4P, Member Rewards) and quality improvement activities as directed by Quality Management program needs.
  • Coordinate with interdepartmental and internal teams focused on process improvement projects and outcomes.
  • Internal and External Medical Record Review Training:
    • Responsible for all HEDIS/QARR medical chart review training.
    • Updates the medical record review training guide.
    • Maintains training and support materials for medical record review of supplemental and hybrid measures, i.e., Training Manuals, Tip Sheets, Presentations, Code Sheets.
    • Conducts training sessions for internal reviewers, providers, and other MetroPlusHealth departments.
    • Assist in implementation of quality improvement activities as directed by Quality Management programming needs. Facilitate interdepartmental and internal teams focused on process improvement projects and outcomes.
  • Medical Record Review Project Supervision:
    • Participate in the annual HEDIS and QARR hybrid medical record review project.
    • Provide coordination, support, and oversight of chart requests and reviews of EMR and non-EMR (mail, fax, email) sources.
    • Interact with the NCQA-approved auditor as needed.
    • Serve as a final reviewer of HEDIS and QARR records.
  • Other duties as assigned by Vice President of Quality Management.

• Associate’s degree required. Bachelor’s degree preferred
• A minimum of 10 years of experience in quality improvement and medical record review HEDIS/QARR in a managed care setting required including 5 years of supervisory experience
• Advanced project management skills.
• Experience supervising remote and/or field-based teams; ability to motivate team members located off site.
• Experience building and maintaining relationships with providers and office staff.
• Advanced experience using EMR systems, e.g., EPIC, Quadramed.
• Proficiency in Microsoft Office applications including Word, Excel, PowerPoint, and Access.
• Knowledge of ICD-10 and CPT codes.
• Prior clinical experience, training, and education preferred
• Ability to travel within the MetroPlusHealth service are
• Current NYS License as LPN, RN, LMSW, LCSW, MD, or NP preferred but not required

Professional Competencies

• Ability to proficiently read and interpret medical records.
• Ability to measure compliance and identify deficiencies in chart documentation against standards.
• Ability to work in a team setting and independently prioritize projects and assignments.
• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication
• Bilingual a plus
• Strategic, data-driven, self-motivated skills