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Successful submission of NCQA Meaningful Use/PIP CPC Plus and other external reporting for clinical quality. Provide guidance and leadership of process improvement initiatives for NCQA Meaningful Use MACRA Coastal Core and other clinical quality programs.
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Direct the activities of divisional staff assigned to support the Enterprise Illinois Plan’s Quality Improvement Programs to ensure ongoing readiness for NCQA/URAC accreditation and/or regulatory (CMS/state) audits and achieve accreditation deemed appropriate for GGR.•Work with the Enterprise Quality Reporting (EQR) team to identify line of business and regional variations in clinical quality measures and population health statistics to inform targeted solutions.
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Also, ensures that site visits and results are clearly documented and tracked within the provider data management database for NCQA reporting requirements. Participates in provider surveys and communications required for NCQA compliance, providing evidence through necessary reporting.
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CHC is designated as a federally qualified health center and a patient-centered medical home by HRSA, the Joint Commission, and NCQA, respectively. Work with Project ECHO providers on site to ensure that all patients enrolled in SA expansion services are entered into CHCI database and appropriately flagged in CHC EHR.Ensure the detail, accuracy and timeliness of data entry and reporting.
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Knowledge of outcomes management, quality reporting components, CQI quality management principles and program, accreditation and regulatory processes, such as National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS) and Michigan Department of Health and Human Services (MDHHS.
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Knowledge of CMS, NCQA and AHCCCS reporting requirements. Collect, analyze, and complete an initial review of provider data as requested & required for department regulatory reporting while establishing schedules to collect & interpret the data.
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Under the general direction of the Vice President of Physician Practices is responsible for planning, organizing, and directing all functions of the Licking Memorial Health Professionals quality improvement programs based on current knowledge of NCQA standards, P4P industry standards, quality improvement methods and all Licking Memorial Health Professionals (LMHP) quality improvement/incentive plans.
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Interface with delegated groups, complete required auditing and reporting related to delegation, and ensure adherence with NCQA requirements for assigned function. + Communicate reporting requirements and related activities to delegated entities.
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Reporting to the Population Health Manager, this position leads the Population Health team by guiding the development, implementation, and monitoring of population health programs and quality improvement activities to advance health equity.
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The Manger of Delegation Oversight and Compliance is also responsible for management and oversight of all regulatory audits, compliance activities, reporting responsibilities, and implementation, completion and monitoring of any corrective actions related to audit findings of all Memorial Care Select Health Plan books of business:Plan-to-Plan Medi-Cal and Commercial, and Large Group Commercial lines of business.
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Assists in the development of any required reporting and monitoring assessments in compliance with NCQA standards. As applicable, ensures local care delivery is in compliance with all payor, State, Federal, NCQA, and contractual requirements through implementation/recommendation of appropriate quality controls, checks and balances.
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Prefer knowledge of medical terminology and regulatory agencies such as federal, state, CMS (fka HCFA), DMHC, and NCQA. Proficiency with Windows, Microsoft Office (Word, Excel, Outlook, PowerPoint, Internet Explorer) including the ability to utilize electronic medical records database and reporting functions.
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May support the NCQA Accreditation Program and oversight processes, accreditation best practices and on-going training activities. ESSENTIAL JOB FUNCTIONS:Serve as the UM Compliance Specialist with Delegated Health Plan contacts for reporting deliverables.
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Monitor and promote improvement or maintenance of local/federal clinical performance metrics and certifications (ie HRSA, NCQA, PCPCH, CCO) within CCC’s Primary Care programs. This includes immediate reporting of any PHI breach of CCC or outside provider health records to the CCC Legal and Quality departments, as well as to the program administrator.
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Conduct formal presentations, reporting results from oversight of delegated Behavioral Health continuity and coordination performance Medical Management audits, HMO Clinical Quality Improvement QI Fund Projects, and provider appeal data analysis at project-specific, HEDIS and Quality Improvement Workgroups.
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