Quality Risk Management Analyst

Responsibilities

• Collaborates with claims adjustors and defense counsel in managing claims including assessment of liability, ensuring establishment of appropriate reserves, maintaining complete and up-to-date case files, and assisting in procurement of medical records and documents necessary for evaluation and defense of cases.
• Facilitates timely response and investigation of adverse and significant events.
• Collects and evaluates data concerning incident reports, aggregates data summaries, and develops monthly and quarterly risk management reports that provide a summary of current claims and litigation, to include an analysis of trends.
• Shares reports with appropriate leadership and advises and recommends actions for process improvement.
• Maintains an accurate, up-to-date database reflecting the status and essential elements of current claims and litigation.
• Analyzes patient concerns or complaints to determine the root of the matter, identifies any trends, and determines how best to address the concern or complaint.
• Reviews and gathers pertinent information from patient records.
• Collaborates with other risk staff in the prompt, equitable resolution of claims.
• Provides consultative and resource support to staff regarding all aspects of risk management.
• Coordinates, facilitates, implements and participates in care management and quality improvement initiatives.
• Collaborates with leadership and departments throughout Aurora and/or Aurora at Home (AatH) on process improvement plans to analyze, monitor and ensure high levels of quality and performance.
• Identifies opportunities for improvement and makes recommendations for change and implements them.
• Participates in medical record review against set guidelines and best practices to determine if care provided was within standards of care.
• Reviews, trends, and reports results of quality related state or federal visits, accreditation, and risk cases to leadership.
• Acts as a resource for other staff, leadership and physicians regarding quality management and risk management issues or topics.
• Collaborates in the development, delivery and evaluation of educational programs or tools that relate to safety, risk management and quality initiatives; may conduct quality and risk management educational programs for the agency.
• Assists with carrying out established processes for risk identification, risk investigation and risk reduction that may include risk surveys, inspection of patient care areas and chart auditing.
• Facilitates root cause analysis investigations, FMEA methodologies, reporting of adverse, significant and sentinel events.
• Complies with various codes, laws, rules, and regulations concerning patient care, including those mandated by state and federal agencies; assisting with the investigation activities of federal, state, and local enforcement authorities.
• Maintains current knowledge of state and federal regulatory and accreditation requirements including accrediting standards for home health, hospice, DME and IV Infusion: HCFA; OSHA; CDC, CLIA waivers.

Qualifications

• Licensure/Certification: None required.
• Education: Bachelor's Degree in Risk Management or related field.
• Experience: Typically requires 5 years of experience in healthcare quality and/or risk management, including experience in risk management principles and continuous quality improvement tools and concepts.

Skills & Abilities

• Knowledge of federal, state and other external health care regulations and standards and ability to research those regulations.
• Knowledge of evidence based, best practice resources to promote efficiency and effective outcomes.
• Working knowledge of process improvement methods and statistical tools.
• Effective conflict management and resolution skills.
• Basic working knowledge of medical terminology, clinical concepts and disease management.
• Intermediate computer skills including experience in using Microsoft Office (Excel, Word, Power Point, Access) or similar products.
• Strong written and oral communication skills including good presentation skills.
• Detail oriented with excellent organizational skills.
• Must be a team player with ability to interact with all levels of staff often in sensitive situations.
• Demonstrated analytical and problem solving skills to track outcomes.
• Ability to influence change without direct authority and strong negotiation skills.

Physical Requirements & Working Conditions

• Exposed to a normal office environment.
• Position requires travel; therefore may be exposed to road and weather hazards.
• Operates all equipment necessary to perform the job.