Job Description

Location: Novato

Employment Status: Full Time

Clinical Review Specialists are responsible for reviewing patient medical records to identify chronic conditions to be prioritized and addressed by healthcare providers. The review process includes working with multiple electronic health records, completing both pre and post-appointment reviews and reviewing capture of chronic conditions for physician incentives. They must maintain best practices for accurate data collection and adhere to Meritage policies and procedures.

Responsibilities
Evaluate the patient’s medical record and reports from the health plan to identify and document potential chronic conditions to be addressed by healthcare providers.

Complete post-appointment review to assess Hierarchical Condition Category (HCC) capture by providers and document findings.

Work with team to ensure ICD10 codes submitted by physicians are supported by documentation. Provide feedback to inform physician education.
Collaborate with team members to research or answer any coding questions that may arise.

Travel to Network Member offices to assist in education of providers and staff regarding coding procedures and policies and to ensure compliance with HCC capture. The Clinical Review Specialist may stay embedded with a network member’s office for an extended period of time.

Maintain excellent customer relationships with providers, medical office staff and health plan representatives.

Complete assigned daily tasks in a timely manner- all tasks are time sensitive

Participate in audits required by each health plan by finding chart notes in different EHR systems and sending to plans on appropriate due date.

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Job Requirements

Education and Experience
Graduate of an accredited coding program or Medical Assistant program. Certified Coder highly desirable.
Familiarity with HCC codes and Risk Adjustment Factor (RAF) model preferred.
High School diploma or equivalent
Ability to multi-task and address competing priorities.

Qualifications
Medical background/ chart review experience required.
Working knowledge of medical terminology. Familiarity with anatomy and physiology, disease processes and pharmacology highly desirable.
Able to use different electronic health record systems as needed.
Detailed oriented and able to work as a collaborative and positive team member.
Strong written and verbal communication skills
Comfortable using Microsoft Excel
A valid California Driver License and proof of insurance required.

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Benefits

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Job Description

Location: Novato

Employment Status: Full Time

General Summary

This position coordinates utilization review and case management activities for commercial and Medicare enrollees.  The Utilization Management nurse is knowledgeable about the Nurse Practice Act, NCQA, Millman Care Guides, and the Center for Medicare and Medicaid, HMO timeliness rules and pertinent state and federal regulations.

• Review routine referral/service requests on assigned patients in accordance with NCQA timeliness standards and health plan benefit structure.
• Prepares and presents cases for medical director review in a concise, objective and organized manner.
• Assists with identifying patterns and trends and develops and implements corrective actions when necessary.
• Educates and supports members in the accessing care using their HMO and Medicare Advantage benefits as needed.
• Review routine referral/service requests on assigned patients in accordance with NCQA timeliness standards and health plan benefit structure.
• Identifies and refers patients to disease management, wellness programs and community resources whenever relevant.
• Assesses members’ physical, psychological, social, environmental, financial and functional status as necessary and informs the patient’s treating physician of clinically relevant findings e.g. positive score of depression screening, non-compliance with the plan of care and barriers t treatment.
• Collaborates with the concurrent review.

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Job Requirements

Qualifications

Education: 

• Current California RN License with no restrictions
• BSN Preferred

Experience:   

• Minimum five years of clinical experience.

• Experience strongly preferred in one or more of the following: HMO, Health plan, Medicare, Utilization Management, Case Management

Knowledge, Skills, and Competencies

• Ability to understand and facilitate communication among team members, patients, families, physicians and medical office staff.
• Ability to communicate effectively with contracted health plans and meet required turn around times
• Good clinical judgment, critical thinking skills and independent problem resolution
• Ability to organize and prioritize workload
• Good working knowledge of Microsoft Office, Outlook, EHR, prior Health Care Management/authorization software.

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Benefits

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Job Description

Location: Novato

Employment Status: Fulltime

Business Intelligence (BI) Analyst, Lead

The Business Intelligence (BI) Analyst, Lead develops and supports the transformation of data into information to provide actionable insights to enhance and expand the quality, efficiency, and cost effectiveness of products and services provided by Meritage Medical Network to its members, physicians, health plans, and staff.

The BI Analyst Lead utilizes established data sources within SQL, Access databases, Excel tables and Power BI  to collect, integrate, extract, analyze and present information in reports, dashboards, and key data visualizations. The BI Analyst Lead, under direction of the IT Director, provides analytics staff work distribution, peer review, and coaching.

The preferred candidate demonstrates advanced SQL, Access, Excel and Power BI skills to create data views, reports, extracts, and visualizations within a healthcare managed care environment.

Essential Job Functions

Ability to transform data into actionable and tailored information visualizations designed for specific issues, operational and/or executive decisions and insights.

Regularly applies conceptual knowledge, analytical methods, and problem solving skills to perform assignments and improve efficiencies within existing systems, processes, functions, and applications.

Provides IT solutions and services which ultimately contribute to physician efficiency, productivity, quality, and organizational clinical, operational, and financial performance.

Advanced analytical and problem solving skills.

Determines operational feasibility by evaluating analysis, problem definition, requirements collection, solution development, and proposed solutions.

Documents and demonstrates solutions by developing documentation, flowcharts, layouts, diagrams, charts, code comments, clear code and appropriate metrics.

Project management training & skills to organize, document, monitor, manage, and communicate project status, issues, risks and associated mitigations and/or resolutions.

Prepares and installs solutions by determining and designing system specifications, standards, and programming.

Improves operations by conducting complex systems analysis, tracking metrics, recommending changes in processes, policies and procedures.

Develops advanced solutions by studying information needs; conferring with users; studying systems/data flow; data usage, and work processes; investigates problem areas; follows industry standard/best practice for software development life cycle.

Ability to be flexible in an environment of changing priorities and work both independently and in a team.

Self-motivated with the ability to prioritize, meet deadlines, and manage changing priorities.

Key Responsibilities

Works closely with end users to understand their business needs in relation to software functionality.

Analyzes software problems and business data requiring complex methods to ensure accurate findings and applicable recommendations.

Designs, delivers, and improves software applications training programs and related courseware.

Understands the end users’ business needs, works closely with them to provide solutions, and aligns end user business needs with high levels of application functionality.

Provides technical support to less experienced information systems analysts.

May serve as a liaison between vendors, IT, and internal customer to ensure service delivery agreements are met and that return on investment is realized.

Updates job knowledge by studying state-of-the-art analysis, visualization, and development tools, programming techniques ;participates in educational opportunities; reads professional and technical publications; maintains personal networks; participates in professional organizations

Complies with MMN’s Policies/Procedures protecting patient information and the confidentiality of the information in accordance with the Federal and State regulations.

 

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Job Requirements

• Bachelor’s degree in related healthcare, business, computer science, information sciences, software development/analysis or related field preferred; experience or alternative degree or alternative knowledge acquisition may be considered in lieu of education.
• Minimum of 6 years of experience within a data analysis environment, with 4 of those years preferably within a healthcare related and/or managed healthcare setting preferred; alternative experience acquisition or a combination may be considered in lieu of required experience.
• Demonstrated knowledge of concepts, practices, processes and procedures used specifically within a managed healthcare environment.
• Previous experience in the analysis, development, support, maintenance and training of a OTF and developed systems required.
• Demonstrated advanced skills in developing solutions in environments that are most applicable to the project requirements, including but not limited or exclusive to: Database (SQL, Access); Spreadsheets (MS Excel); Data Visualization (Microsoft Power BI); FTP scripting; Crystal Reports;  a plus to have:  Web (HTML, CSS, JavaScript, AngularJS, etc.); Desktop (.Net, C#, VB, etc.); etc.
• Strong skills using MS Office 365 – Outlook, Access, Excel, Word, PowerPoint, Skype, Teams, and Visio.
• Familiarity with specialty applications for project and resource collaboration (e.g., SharePoint, Asana, MS Teams)

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Benefits

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