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Mssp Clinical Chart Review Auditor Resume

Raleigh, NC

PROFESSIONAL SUMMARY:

  • To obtain a position that will utilizing healthcare information management experience and my al expertise in the healthcare industry.
  • Concentrated in Information Technology/ Architecture, with exposure to Common End - user Software/ Data Centric.
  • Over twenty years medical and clinical experience in hospital and insurance industries.
  • Demonstrated record of, proficient in crises, excellent interpersonal skills, well organized, and results driven.

EXPERIENCE:

Confidential, Raleigh, NC

MSSP CLINICAL CHART REVIEW AUDITOR

Responsibilities:

  • Coordinates and performs onsite data collection and data entry, when possible data collection can be performed remotely via scanned/faxed documentation.
  • Utilizing Clinigence database and maintaining updated clinical information daily per audit criteria.
  • Responsible for weekly and daily reports.
  • Responsible for complete and accurate medical record review of charts collected from provider offices and the abstraction of critical data from medical records received via on site, fax, mail, or electronic means for all MSSP measures for the designated population.
  • Apply structured auditing criteria to medical records to determine compliance with standards of the established performance measures; and accurately enter the results of chart audits into a database.
  • Develop and manage regular, ongoing data collections processes to ensure timely collection of data, thereby ensuring regulatory deadlines are met as well as client data requirements or requests.
  • Process all abstracted information through record upload or data entry methods.

Confidential, Raleigh, NC

ROI/CLIENTSERVICE REPRESENTATIVE

Responsibilities:

  • Completes release of information requests including retrieving patient’s medical chart and returning chart, scanning medical record accurately and correctly and transmitting daily, according to requests, established procedures, and established standards of quality and productivity.
  • Utilizing Prizm, ESmart log, and SMART Request databases daily to process ROI requests from various providers.
  • Validates requests and authorizations for release of medical information according to established procedures.
  • Ascertains that all releases of information are in compliance with the request, authorization, company policy and HIPAA regulations. travel to various physician/hospital sites during the course of the day
  • Performs quality checks on all work to assure accuracy of the release, confidentiality, and proper invoicing.
  • Carries out responsibilities in accordance with Company and client/site policies and procedures, including HIPAA, state/federal regulations related to operations, and labor regulations.
  • Maintains confidentiality, security and standards of ethics with all Company and medical records information including during transport, storage and disposal.
  • Work with privileged information in a conscientious manner while releasing medical records in an efficient, effective, and accurate manner.
  • Maintains working knowledge of the existing state laws and fee structure

Confidential, Durham, NC

HEDIS Data Abstractor Consultant

Responsibilities:

  • Reviewing and comparing data abstracted from medical records by third - party vendor with the appropriate measure guidelines;
  • Researching any discrepancies found by reviewing medical records, claims data and any other relevant information;
  • Identifying trends and documenting any errors found;
  • Demonstrating expertise in the requirements and parameters of mandated HEDIS performance measures;
  • Applying structured auditing criteria to medical records to determine compliance with HEDIS standards;
  • Maintaining productivity levels as determined by the Quality Improvement Department;
  • Accurately entering the results of chart audits into a database (e.g. Quality Reporter);
  • Monitoring progress towards completion of the annual HEDIS chart abstraction process;
  • Utilizing various software applications (e.g., Quality Reporter, Excel and Word) to support HEDIS operations.

Confidential, Durham, NC

Field Clinical Chart Reviewer

Responsibilities:

  • Travel to and from physician's offices, hospitals, and outpatient facilities
  • Utilizing DaVanci database daily to update necessary clinical information.
  • Review medical charts at various medical facilities using company provided equipment
  • Upload scanned medical charts to the corporate data center using your high-speed internet connection.
  • Extensive knowledge of medical records and terminology, anatomy and physiology
  • Reviewing pertinent clinical information for HEDIS reporting and other clinical indicators.
  • Complies with all aspects of EMS's code of conduct including but not limited to Compliance with the Law and Regulations, Security Policies and Practices, Honesty and Fairness, Diversity and Respect, Conflict of Interest, Confidentiality, Health Care Fraud, Waste and Abuse.

Confidential, Raleigh-Durham, NC

Field Clinical Chart Reviewer

Responsibilities:

  • Travel to and from medical offices, hospitals, and outpatient facilities.
  • Upload scanned medical charts to the corporate data center using your high-speed internet connection.
  • Extensive knowledge of medical records and terminology, anatomy and physiology.
  • Reviewing pertinent clinical information for HEDIS reporting and other clinical indicators.
  • Proficient computer skills and be capable of utilizing various EMR systems
  • Works independently in a professional manner.
  • Strong communication & organizational skills
  • Complies with all aspects of ECS’s code of conduct including but not limited to Compliance with the Law and Regulations, Security Policies and Practices, Honesty and Fairness, Diversity and Respect Conflict of Interest, Confidentiality, Health Care Fraud, Waste and Abuse.

Confidential, Linthicum, MD

Clinical Quality Improvement Coordinator

Responsibilities:

  • Design, direct and oversee implementation of clinical quality improvement programs with the guidance of the Clinical Committee
  • Support member health centers in developing and implementing the necessary teams, tools and care process changes in parallel with individual center efforts to improve patient outcomes and develop innovative approaches to primary care delivery reform.
  • Participate in the critical analysis of individual center and network aggregate results of existing clinical outcome measures, while working closely with quality management senior staff and informatics resource personnel to develop additional performance measures.
  • Work closely with implementation staff to ensure that all clinical setup and workflow development is aligned with QI program requirements, goals and objectives.
  • Participate in on - going development of clinical data repository and dashboard reporting.
  • Participate in monthly Clinical Committee meetings and perform requested follow-up duties.

Confidential, White Plains, NY

Quality Improvement Coordinator

Responsibilities:

  • Helps quality improvement (QI) manager to plan, design, implement, and maintain a comprehensive medical practice continuous quality improvement (CQI) program including utilization management and risk management. Assists in educating new staff, including physicians, about QI systems and requirements.
  • Meets with internal and external audiences to identify and problem solve QI issues.
  • Monitors medical practice efforts to ensure compliance with internal and external QI standards. Reviews medical records and other documentation to ensure quality care. Helps to prepare annual QI report.
  • Coordinates the effort to gather data and prepare reports to meet the requirements of NCQA and other regulatory/accrediting agencies, including patient satisfaction data.
  • Evaluates variance and other data to identify QI opportunities and risk management issues.
  • Monitors utilization and service quality through diagnosis-related group (DRG) review, HEDIS quality measures, payer/provider/patient satisfaction surveys, and complaints. Follows through on complaints including identification of corrective actions needed. Reports on results.
  • Knowledge of CQI principle, practice, methods, and tools.
  • Knowledge of computer applications related to QI, including spreadsheets.
  • Knowledge of medical records and clinical care processes.

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