Quality Improvement
The Quality Improvement Department combines quality assurance activities ( such as retrospective monitoring and problem solving associated with the quality of care delivered ) and continuous quality improvement ( such as the trending and analysis of ongoing aggregate data for planning ).
The department uses standard measurement sets ( HEDIS and CAHPS ) developed for health plans to monitor quality indicators for care and service .
Reimbursement Services
The Reimbursement Services Department provides accurate and timely processing of claims , delivers coordination of benefits and subrogation services and assists in the resolution of customer complaints , appeals and grievances regarding claims . The department also performs quality audits of claims and works with other departments to ensure that Hometown Health reports accurate data to internal and external agencies .
Risk Adjustment Department The Risk Adjustment Department ensures the integrity and accuracy of data submitted to CMS through data quality review , medical chart review and Risk Adjustment education / training for providers and other healthcare professionals focusing on compliant documentation and diagnosis coding .
Sales and Retention
The Sales and Retention Department sells new commercial business , works to retain existing business and responds to Requests for Proposals ( RFPs ). In addition , the Sales and Retention Department serves our self-funded employer clients by coordinating third-party administrator services , including proposals , benefit set-up , and reporting . The Department serves as a consultant to our clients on benefit design , plan provisions and changes that require action by our clients . Sales and Retention develops partnerships with brokers , agents , consultants , and employer groups .
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