Quality Program Specialist - Temp

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PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The Quality Program Specialist will work directly with internal PacificSource Risk Adjustment team processing all medical record requests in a timely and efficient manner ensuring accuracy and providing the highest quality medical record. The Quality Program Specialist must always safeguard and protect the patient’s right to privacy by ensuring that only authorized individuals have access to the patient’s medical information and that all releases of information follow the request, authorization, PacificSource Health Plans company policy, and HIPAA regulations.

Essential Responsibilities:

• Receives incoming requests for medical records and responds to request in timely and efficient manner ensuring the correct medical record is obtained and valid for risk adjustment review purposes.
• Validates requests and authorizations for release of medical information according to established procedures and HIPAA guidelines.
• Performs quality check on all chart retrieval workbooks to verify accuracy of the records before submission to coding.
• Ability to work with minimum supervision, organize workload and prioritize work tasks to meet production goals.
• Communicates with Manager on an on-going basis, providing information and data as requested including retrieval feedback needs and requests.
• Promptly reports to Manager any customer service concerns and/or any potential HIPAA violations whether actual or perceived.
• Management of member records including file storage that’s in alignment with HIPAA laws and regulations and in compliance with Business Associate Agreements.

Supporting Responsibilities:

• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: 2 years of experience in the health insurance or medical industry required or equivalent education/experience. Experience with Medicare preferred.

Education, Certificates, Licenses: High school diploma or equivalent required. Associate degree preferred.

Knowledge: General knowledge and understanding of medical terminology, ICD-10-CM, CPT, and health insurance. Ability to review, evaluate and present quality medical records and reports. Good organizational skills with experience in using computers and various software applications including Word, Excel, PowerPoint, Outlook, and audio-visual equipment. Knowledge/experience with Medicare quality programs (CMS 5-Star, HEDIS, risk adjustment) preferred. Must have strong analytical and problem-solving skills. Ability to effectively communicate with all levels of staff and management. Must be self-motivated, organized, and detail oriented. Ability to work independently with minimal supervision.

Competencies

Adaptability

Building Customer Loyalty

Building Strategic Work Relationships

Building Trust

Continuous Improvement

Contributing to Team Success

Planning and Organizing

Work Standards

Environment: Work inside in a general office setting with ergonomically configured equipment.

Skills:

Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:

$44,982.98 - $71,972.77

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.

• We are one team working toward a common goal.

• We are each responsible for customer service.

• We practice open communication at all levels of the company to foster individual, team and company growth.

• We actively participate in efforts to improve our many communities-internally and externally.

• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.