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Demonstrated knowledge of Hospital/professional billing and reimbursement Medicare and Medicaid denials and appeals Third Party Contracts NCQA guidelines for denials and appeals. Receives reviews and monitors progress reports from medical records ancillary and other departments (using provider liable reports medical necessity and ABN reports written order exception reports un-coded accounts receivable reports etc) related to denials/appeals and takes the necessary steps to implement positive change.
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Serves as the Georgia liaison to National Provider Contracting and oversees implementation of best practices to improve organizational effectiveness. Basic Qualifications:ExperienceMinimum fifteen (15) years of progressive responsibility in health care with at least ten (10) years of direct provider contact in network development, contracting and/or provider relations.
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Preferred: Quality Improvement License: Licensed Practical Nurse (LPN) or Registered Nurse (RN) Certifications: Basic Life Support Health Care Provider (BLS-HCP) Minimum Work Experience 3 years healthcare experience 1 year in ambulatory care setting (Preferred) Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran.
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Located in Renton, Washington, Valley Medical Center is the largest not-for-profit healthcare provider between Seattle and Tacoma, serving more than 600,000 residents. Patient-Centered Medical Home by the National Committee for Quality Assurance (NCQA.
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This position will work closely with the CM Director as well as internal and external stakeholders (including, but not limited to, key internal teams such as Population Health, Quality Improvement, Provider Network, Compliance and Medicare/Medicaid Administration, along with providers and community partners) to develop and lead CM initiatives in accordance with CMS, OHA and NCQA requirements.
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3 or more years of experience in Compliance, Audit, CAG, SIU, provider services or member services department within a health care organization. Participate in External Audits, e.g. Health Plan Customers, CMS, DHS, NCQA, etc.
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Analyze and interpret data in collaboration with other departments to identify population health cost savings and care improvement opportunities across the continuum of care and make recommendations for innovative initiatives and integrated health strategies with provider partners.
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JOB DETAILS:-Primary care practice with a patient panel ranging in the full lifespan (birth to geriatrics)-Robust EHR (Epic 10-Star health system top 1% of Epic organizations)-Easy access to Guthrie Specialists-All locations accredited Patient Centered Medical Home under the NCQA standards-Physician-led environment that is driven by physician and provider collaboration-Flexible scheduling-FT providers have Patient-facing time + 4 hours of admin time-Guthrie will assist in licensing for NY/PA.
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Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Serve as the IEHP Liaison between hospitals, IPAs vendors, outside agencies and provider to ensure effective communication and collaboration in an effort to meet the Member's treatment plan and goals.
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Prepare credentialing audit reports tracking and trending auditor findings and assist in the formulation of staff training guides, policies and procedures Manages multiple concurrent audits, plan audits and related projects ensuring all audit tools comply with NCQA, TJC and CMS requirements Coordinates the credentialing and re-credentialing process for assigned providers.
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Accountable for strategic development, implementation and oversight of a multi-year Government transformation and improvement strategy by leading efforts in collaboration with internal and external stakeholders such Population Health, Quality Improvement, Behavioral Health, Compliance and Provider Network along with providers and community partners.
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The AVP, Accreditation & Compliance leads NCQA Accreditation and Certification program management and oversees ongoing compliance to all requirements. member and provider satisfaction survey development, fielding, vendor management and analysis, supporting new business development/RFP decision making related to accreditation and certification process, rules and implementation timelines.
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Knowledge of compliance and regulatory requirements for member and provider care and service, including CMS/ Medicare Advantage, NCQA. Clinical Trainer and Quality Assurance Specialist serves as a subject matter expert to ensure DS system clinical staff (MA, LPN, RN) are effectively onboarded and maintain current evidence based clinical competencies necessary for compliance with NCQA, State/Federal and other applicable regulations.
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Healthcare: SAC Health System is recognized as a Level-3 Patient-Centered Medical Home by the National Committee for Quality Assurance (NCQA). This whole-person, full-scope, team-based approach is what makes SAC Health System the provider of choice for patients.
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Medicaid provider data, provider relations, or provider contracting experience. The role will collaborate cross functionally with Compliance, Legal, local Medicaid Health Plans, Medicaid Network Contracting and Medicaid Provider Relations, and other departments to maintain compliance of provider related tasks.
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