Position Location: MA - Boston AAP Reporting Location: MA - Boston (MBHP) ID: 51337 Job Family: Quality Management / Performance Improvement Functional Area: QUALITY MANAGEMENT FTE Status: Part time Scheduled Weekly Work Hrs: 20 Workday Schedule: Weekdays Only Workday Start Time: 8 am Workday End Time: 12 pm Variable Work Schedule:
ABOUT THE POSITION We are currently seeking a dynamic MEDICAL RECORD REVIEW ANALYST to join our team at our office in Boston, MA. The MEDICAL RECORD REVIEW ANALYST supports Massachusetts Behavioral Health Partnership (MBHP'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. Will work in conjunction with the Medical Record Review Manager to ensure timely completion of all contractual, NCQA required, and ad-hoc medical record reviews. Conducts medical record reviews aimed at identifying potential instances of fraud and abuse. Ensures organizational compliance with HIPPA and Privacy laws. Position Responsibilities:
Provides support to MBHP Medical Record Review Manager for all record review activities as needed.
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
Utilizes claims-based data, reports and quality of care concern information to guide record review activities aimed at identifying potential provider fraud and abuse.
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.
Provides technical assistance to providers and internal staff regarding best practices in the management of medical records.
Ensures the completion and accuracy of record review summaries following each review and documents this activity in MBHP's Quality Department database.
Completes written summary reports and provides feedback to providers with opportunities for improvement as 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.
Engages Claims department staff for issues of recovery of payment and questions of provider accurate claims submission as necessary.
Sustains spreadsheets and databases of medical record reviews and quality improvements plans.
Support pay-for-performance projects, MBHP contractual requirements, and ad-hoc requests from various internal departments by performing medical record reviews.
Supports the Compliance director by providing internal staff consultation to ensure programmatic adherence with relevant HIPPA and Privacy standards.
Completes periodic internal MBHP audits to ensure compliance activities and work groups to ensure organizational adherence with new updated national and state regulations for Compliance.
Assesses organization needs pertaining to Compliance and develops relevant staff training and education based on organizational needs.
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. 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.