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Position Location: MA - Boston AAP Reporting Location: MA - Boston (MBHP) ID: 51336 Job Family: Quality Management / Performance Improvement Functional Area: QUALITY MANAGEMENT FTE Status: Full time Scheduled Weekly Work Hrs: 32 Workday Schedule: Weekdays Only Workday Start Time: 8 am Workday End Time: 5 pm Variable Work Schedule:
ABOUT THE POSITION We are currently seeking a dynamic MEDICAL RECORD REVIEW MANAGER to join our team at our office in Boston, MA. The MEDICAL RECORD REVIEW MANAGER will plan, organize and direct MNHP's Record Review Program for the purpose of ensuring quality of care, documented services meet medical necessity criteria and verifying documentation support for all claims related activity to sampled records. The Medical Record Review Manager will coordinate with the Medical Record Review Analyst to designate record review assignments. Upon completion of record review, the Medical Record Review Manager will develop follow-up plans and recommendations for providers in concert with appropriate internal staff. Position Responsibilities:
Responsible for the design and implementation of MBHP's medical record review program through which medical records for all covered services at all levels of care are audited.
Ensures that medical record review criteria meet industry standards and other relevant laws and regulations as applicable.
Ensures provider adheres with MBHP Performance Specifications through performing medical record reviews
Supports pay-for-performance projects, MBHP contractual requirements, and ad-hoc request from various internal departments by performing medical record reviews.
Manages major Medical Record Review deliverables such as annual Clinical Practice Guideline and MBHP contractual required Inpatient Medical Record Reviews.
Ensures the reliability of medical record reviews by directing inter-rater reliability evaluations with all staff involved in medical record review projects to ensure consistent implementation of record evaluation criteria.
Work closely with the Medical Record Review Analyst to ensure timely completion of all required contract, NCQA, and ad-hoc record review projects.
Arranges and schedule provider visits, coordinates provider notification and manages provider expectations for on-site reviews.
Generates requests to obtain provider-specific claims-based data for designated reviews.
Ensures the completion and accuracy of record review summaries following each review and aggregate reports of program productivity completed monthly.
Completes written summary reports and provides feedback to providers with opportunities for improvement are identified and documented.
Develops quality improvements plans for providers that do not meet MBHP Health Record Standards.
Engages Regional Network Management staff to ensure provider compliance with quality improvement guidelines.
Provide technical assistance to providers and internal staff regarding best practice in the management of medical records.
Engages the Reporting department staff for issues of medical record sampling and data management.
Sustains spreadsheets and databases of medical record reviews and quality improvements plans.
Completes trend analyses of medical record review to guide provider specific and network-wide quality improvement interventions.
Completes follow-up record reviews in response to quality of care issues identified through the investigation of Adverse Incidents, Member Grievances and Provider Concerns.
Develops trainings and provider's education to internal staff pertaining to MBHP Record Review activities and industry standards for high quality medical record documentation.
Position Requirements: Education: Master's level clinician, RN Licensure: LICSW, LMHC, LMFT Relevant Work Experience: 5 Years of professional experience in the mental health and /or substance abuse field, including one year as a supervisor. General knowledge of managed care, quality management, and utilization management principles preferred. Knowledge, Skills & Abilities:
Strong communication skills, both oral and written
Beacon Health Options is a health improvement company that serves 45 million individuals across all 50 states and the United Kingdom. On behalf of employers, health plans and government agencies, we manage innovative programs and solutions that directly address the challenges our behavioral health care system faces today. A national leader in the fields of mental and emotional wellbeing, recovery ...and resilience, employee assistance, and wellness, Beacon Health Options helps people make the difficult life changes needed to be healthier and more productive. Partnering with a network of providers nationwide, Beacon Health Options helps people take important steps in the right direction. We help them live their lives to the fullest potential. Visit www.beaconhealthoptions.com for more information.