This job is responsible for providing analytic support for the CHI St. Vincent Health System strategic clinical risk management program which is focused on enhancing patient safety and quality of care and mitigating/minimizing financial loss through risk detection, evaluation, prevention, reduction and resolution. An incumbent researches bills/non-billable events relating to hospital-acquired conditions/sentinel events and participates, under the direction of hospital-based Risk Managers, in the investigation of claims and potential claims.
Work also includes: 1) supporting litigation and insurance processes; 2) researching regulatory requirements and best practices to facilitate implementation of risk strategies/programs to improve patient outcomes and liability risk reduction; 3) analyzing risk-related data to identify trends, differences from benchmark quality data and gaps in standards/processes, and 4) monitors department compliance with corrective action plans.
Work requires knowledge of risk, legal and/or patient safety processes and terminology, and of the objectives of the risk management and/or regulatory/safety functions sufficient to carry out most responsibilities independently. An incumbent uses initiative in carrying out the recurrent work, handling problems and deviations in accordance with established procedures, accepted practice and/or requirements. Guidelines for conducting the work are general, requiring the exercise of independent judgment in determining the most efficient and effective way to achieve desired objectives and in recommending alternative options to billing situations requiring interpretation of complex regulations.
ESSENTIAL JOB FUNCTIONS: The following section contains representative examples of job duties that might be performed in positions allocated to this job class. Roles and responsibilities may be altered to accommodate changing business conditions and objectives as well as to tap into the skills and experience of its employees. Accordingly, employees may be asked to perform duties that are outside the specific work that is listed. It is not required that any position perform all duties listed, so long as primary responsibilities are consistent with the work as described. Performance standards developed for incumbents allocated to this job class may also contain relevant job content information and are referenced hereto.
1. Investigates incidents of hospital-acquired conditions, sentinel events and other incidents involving errors or omissions in the delivery of patient care to identify/clarify non-billable events and coordinate the bill-split process.
Reviews pertinent charts/records/reports and researches/identifies/addresses related risks/issues within defined scope of responsibility.
Works collaboratively with clinical managers, business office and other stakeholders to hold charges until reviewed by the appropriate clinical/hospital department.
Follows up to ensure timely and appropriate resolution of specific cases.
2. Keeps abreast of current relevant regulations applicable to non-billable events and other documentation clarifying application to specific situations; recommends and implements formal procedures/processes to train stakeholders and facilitate regulatory compliance Reviews and analyzes IRIS incident reports to identify opportunities to improve the delivery of safe patient care; develops reports and presentations as directed by Risk Managers.
Prepares and maintains summaries of investigations, recommendations and corrective action plans in an organized and retrievable fashion; assists with follow-up and documentation of implementation of risk reduction strategies.
Identifies gaps in standards/processes with potential to cause adverse patient care/safety outcomes and that increase risk, liability and/or litigation costs to the organization.
3. Maintains database of serious safety events and sentinel events; updates department action plans designed to implement procedural changes and remedial actions to facilitate performance improvements and avoid recurrence of adverse events.
Maintains tracking database and follows up with risk manager and/or department to ensure departments are in compliance with the provisions of the approved action plan and meeting established timelines; identifies non-compliant departments and escalates for management attention.
Updates database to reflect completion/conclusion of department action plans.
4. Researches applicable regulatory requirements and best practices on a regular basis to facilitate the development/implementation of risk strategies/programs to achieve better patient outcomes and liability risk reduction; participates in the implementation, documentation, evaluation and follow-up of risk reduction initiatives/programs/tools; monitors ongoing compliance with loss prevention programs.
Identifies compliance issues and participates in the development of appropriate plans to close the gaps to achieving positive outcomes and minimizing loss exposure and to allow management to respond proactively to the reinforced emphasis on measuring/understanding the quality of care and related safety provided.
Analyzes the impact of current programs/protocols on patient care and safety outcomes; evaluates enterprise data to establish targets and develop action plans to optimize operational performance; understands cause-and-effect relationships within various aspects of programs.
Researches, identifies and validates evidence-based best practices in clinical practice and patient safety to provide guidance to clinical areas in performance improvement activities; researches nature/scope of impact on existing activities and makes appropriate recommendations.
Provides direction to internal operational and support staff on patient safety/risk management requirements/expectations which have an impact on their responsibilities.
Performs continuous data monitoring and reporting; develop deliverables and reports including appropriate dashboards, tables, graphs and maps that clearly and effectively convey the results analyses; assures the integrity of data and reports produced by auditing information submitted to assist in the review of performance improvement initiatives delivered throughout CHI St. Vincent.
5. Gathers information and completes formal documentation in support of claims, litigation and insurance processes; supports data collection relating to the CHI Clinical Risk Management Incentive Plan (CRMIP).
Reviews Notice of Occurrences and retrieves/gathers data from patient charts and electronic medical records systems to support Risk Managers in facilitating claims litigation and support.
Researches/gathers all data relevant to the annual determination of insurance premiums; in collaboration with Risk Managers, completes and submits CHI annual insurance survey and incentive plan; works proactively with facilities management and staff to ensure that incentive plan requirements are met.
Collects and organizes performance improvement data as relates to patient safety and produces charts/graphs and other presentation materials for management review.
6. Performs related duties as required.
MINIMUM JOB QUALIFICATIONS: The following section contains representative examples of competencies and job qualifications directly related to successful performance in the position. The categories are broad, reflecting minimum requirements. It is not intended to be an exhaustive list of all possible requirements nor does it include general competencies, expectations and/or skills that are universally applicable to the work, but are not critical for recruitment purposes or to overall job performance.
Education/Certification/Work Experience Requirements:
Bachelor’s degree in business administration, nursing, healthcare administration, or other related clinical field that demonstrates the attainment of the requisite job knowledge skills/abilities and two years of related work experience (including exposure to legal and medical terminology) - Required.
Paralegal experience - Preferred.
Certified Professional in Healthcare Risk Management (CPHRM) through the American Hospital Association (AHA) - Preferred.
Or any equivalent combination of education and experience which provides the required knowledge, skills and abilities to perform the essential functions of the position.
Knowledge of concepts, standards, best practices, processes and tools relating to patient safety and risk management relating to health care organizations.
Knowledge of the practices and techniques relating to data management/collection and database auditing.
Knowledge of meaning and usage of medical terminology, abbreviations and standard health care codes (CPT, ICD9, etc.) sufficient to perform the duties of the position.
Knowledge of the practices, methodologies and resources relating to the collection, analysis and communication of statistical data and results.
Knowledge of the content and intent of regulatory requirements applicable to matters within designated scope of responsibility.
Knowledge of, and experience in performance improvement methodologies; quality measurement; and data analysis using statistical principles.
Knowledge of legal and medical terminology sufficient to perform the duties of the position.
Ability to present, explain and interpret technical information in a way that establishes rapport, persuades others and gains consensus among individuals having different priorities, requirements and resources.
Ability to read and understand patient records, and to prepare clear, concise and accurate reports/recommendations with respect to non-billable events.
Ability to identify compliance deficiencies and/or systemic weaknesses and implement timely corrective action to forestall or remedy.
Ability to independently conduct routine and non-routine compliance reviews/audits and prepare meaningful, accurate and concise reports.
Ability to recommend and implement plans, processes and tools to improve performance, facilitate compliance, reduce loss and control risk.
Ability to express ideas and convey information effectively in verbal and written communication.
Ability to prepare and maintain accurate reports, records and documentation, and to explain/interpret findings to management.
Ability to understand, apply and effectively communicate applicable policies, standards, procedures and regulations.
Ability to keep abreast of trends, new developments and regulatory requirements impacting matters within designated scope of responsibility.
Ability to read, understand and communicate in English sufficient to perform the duties of the position.
Ability to use office equipment and automated systems/applications/software at an acceptable level.
Ability to establish and maintain effective working relationships as required by the duties of the position.
Requisition ID: 2018-R0181321