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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. Makes recommendations to the Senior VP/Clinical Director and CEO for provider discipline, compliance issues, suspension and termination in accordance with the CHC medical staff bylaws; also completes performance deficiencies for providers in a timely fashion (in collaboration with the VP/CQO where appropriate.
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Maintains individual provider credential files with all the appropriate documentation consistent with AAAHC and NCQA standards. Responsible for daily provider data management and review of credentialing files for accuracy and completeness, utilizing internal and external sources.
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The Advanced Practice Provider (APP) in the Hematology and/or Oncology specialty manages health problems and coordinates health care in acute or specialty care settings. Documents all medical evaluation, diagnoses, procedures, treatments, outcomes, education, referrals and consultations consistent with NCQA, The Joint Commission, state regulatory standards and evidenced-based standards of care.
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Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to CMS, DHCS, DMHC, MRMIB and NCQA standards and regulations. This position will provide resolution of complaints in compliance with Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB) and National Committee for Quality Assurance (NCQA) regulatory requirements.
$60,778 a yearFull-timeExpandApply NowActive JobUpdated Yesterday - UpvoteDownvoteShare Job
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Because SOFHA puts our patients health at the forefront of everything we do, our practices are recognized as Patient-Centered Medical Home Practices by the NCQA. Not only do we foster a community of collaboration and connectivity at State of Franklin Healthcare, but we also recognize the importance of physician wellness, and ensuring the necessary flexibility and balance to have the best possible quality of life as a practicing health care provider.
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3) Conduct in-state provider educational sessions in person on relevant topics such as new business tools, billing/coding, Health e-Blue (HeB), HEDIS, medical record reviews, etc. Knowledge of NCQA HEDIS measures is preferred but will interview qualified RNs. The candidate must be licensed as a Registered Nurse in the state of Michigan and have a dependable vehicle.
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In addition, IEHP is proud to announce the team recently earned NCQA Health Equity Accreditation. Working in collaboration with the Provider Network team to ensure network adequacy in geographical areas in compliance with regulatory requirements and IEHP strategies.
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Reporting to the Manager, Delegation Oversight, the Delegation Operations Auditor, Senior is responsible for ensuring that delegates are compliant with all federal, state, and NCQA regulatory requirements with direct impact on the success of delegate compliance and organization oversight goals and objectives.
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Working knowledge of credentialing/enrollment systems (i.e. Cactus) Certified Provider Credentialing Specialist (CPCS) Experience with CMS/PECOS provider enrollment. Understanding of National Committee for Quality Assurance (NCQA) and Managed Care Plans.
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PREFERRED JOB REQUIREMENTS : RN or post-graduate education in Health Care Administration or a health-related field, public health and/or MBA. extensive experience with HEDIS Quality experience and Medical Management experience in a leading managed care/insurance or provider organization.
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Four (4) years of experience in a Medicaid or Medicare Managed Care role with direct product/program experience in claims, contract compliance, payment methodology, government relations, provider network and day to day operations is required.
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Advises and educates Provider practices in appropriate HEDIS measures, and HEDIS ICD-10 /CPT coding in accordance with NCQA requirements. Collaborates with Provider Relations to improve provider performance in areas of Quality, Risk Adjustment, Operations (claims and encounters.
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4 years directly related to hospital medical staff or managed care credentialing and/or provider enrollment. Minimum 5 years of healthcare experience with 1 year directly related to hospital medical staff or managed care credentialing and/or provider enrollment.
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Maintain working knowledge of Joint Commission, NCQA, State Medical Boards and Centers for Medicare & Medicaid Services (CMS) standards. Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Service Management (CPMSM) OR obtained within twelve (12) months of hire.
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The Risk Adjustment Coding Analyst ensures technical aspects of diagnostic and procedure coding follow CMS, NCQA, third party payers and other regulatory agencies. Using primarily the HCC Risk Adjustment model, conduct training with individual and large provider groups.
$66,000 - $77,000 a yearFull-timeExpandApply NowActive JobUpdated 9 days ago
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