Under the general direction of the Team Manager Clinical Quality & Pt Safety, the Intake Coordinator assists with all operational aspects of the Member Clinical Grievance and QI Occurrence process for Commercial, Senior and Public Plans products. Responsibilities include, but are not limited to timely set up, distribution and classification of clinical grievances and QI Occurrences. Gathering information on behalf of the RN Specialists with providers, external vendors as well as coordinating request for medical records.
The coordinator must possess broad understanding of all products and benefits as well as have an understanding of regulatory requirements and timeframes. The Coordinator routinely interacts with providers and other internal and external constituents.
Essential job functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. These essential functions need to be performed on a consistent and regular basis, using good judgment. The employee must have the ability to learn and apply Tufts Health Plan policies and complex and frequently changing regulatory requirements consistently and the judgment to seek out guidance as needed.
The coordinator must have excellent writing skills with written work requiring minimal oversight by the QM clinical staff and Team Manager Clinical Quality & Pt Safety.
KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS* (in order of importance)
Assign clinical grievances and occurrences to RN Specialists
* Enter initial member data into the system of record and maintain accuracy of appropriate data.
* Classifies clinical grievances and occurrences per department documentation standards
* Gathers information from Tufts Health Plan applicable systems to support investigation
* Outreach to referral source, member or providers for additional information
* Triage Clinical Grievance and QI occurrences per department assignment process
Support the RN Specialists in the completion of clinical grievances and occurrences including but not limited to
* Requesting and tracking receipt of appropriate medical records
* Gathering information and uploading to the system of record any case documentation
* Track and complete clinical grievance AOR process
* Act as a liaison with internal departments relative to the status of a clinical grievance and the research needed to process the grievance.
Processing of Member Clinical Grievances including:
* Receive and complete initial research on clinical grievances.
* Manage clinical grievances not requiring clinician investigation ie. Transportation grievances, subset of Part D clinical grievances)
* Ensure each assigned clinical grievance is categorized per department standard.
* Complete data entry and documentation requirements in multiple information systems including but not limited to MedHOK, Macess and CCMS.
* Act as a liaison with internal departments relative to the status of assigned clinical grievances and the research needed to process the grievance.
* Responsible for meeting and complying with all regulatory and department timelines, policies and
* Responsible for timely communication to Team Manager of any barriers to meeting regulatory timeframes
Perform case documentation according to Department standards including but not limited to timely completion of daily tasks, timely management of assigned clinical grievance and occurrence work with same day case data entry.
Work in conjunction with the RN Specialist to evaluate, discuss and initiate appropriate interventions integral to the QI review process for individual clinical grievances and occurrences.
Participate in projects and/or assignments including, but not limited to, QI initiatives, inter- departmental projects and projects with external customers.