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Knowledge of current National Committee for Quality Assurance (NCQA)/Utilization Review Accreditation Committee (URAC) standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC, and other regulatory standards.
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As part of the Care Team, understands the NCQA Patient Center Medical Home Standards and expectations. We are both a Federally Qualified Health Center (FQHC) and a Community Mental Health Center (CMHC.
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Administers FH authorization processes as outlined in Member Handbook/Evidence of Coverage for all products, and in compliance with applicable CMS and NCQA standards and other state or federal regulatory requirements.
$23.5 an hourFull-timeExpandApply NowActive JobUpdated 2 days ago - UpvoteDownvoteShare Job
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Knowledge of NCQA and/or JCAHO Accreditation standards. Maintains and updates continuing medical education/ACLS credits and other training requirements. Maintains correspondence files and credentialing archival files.
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Working knowledge of IC, DHS, DMHC, NCQA, and CMS Standards. Review claim/referral appeals and unauthorized claims, forwarding them for medical director/UMC review and determination when appropriate.
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Designs, implements and evaluates programs and activities to ensure compliance with regulatory agencies as pertains to nursing and /or patient care services, such as JCAHO, NCQA, HRSA and FTCA. Participates in developing and implementing interdisciplinary outcome standards.
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Participates in committees and teams as representative for nursing staff Works with CFO, CCO and Sr. Leadership to establish annual budget and staffing plan that results in achievement of high quality, low cost of care.
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Consults, designs and produces health care information, business analysis, market analysis, geo analysis, survey analysis and reports to help support senior leadership and organizational priorities in addition to external reporting entities such as the Division of Insurance, NCQA, CMS, etc.
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The Credentialing Coordinator is responsible for processing and completing the credentialing and re-credentialing functions of all providers in accordance with NCQA, state, and federal requirements.
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Experience: 3-5 years of Program and/or Project management experience, with a focus on Quality/HEDIS, NCQA, and operational process improvement. Certifications: PMP, Six Sigma Green Belt, Six Sigma Black Belt Certification, or comparable coursework desired.
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In 2016, CSHC was re-recognized as a Level 3 Patient-Centered Medical Home (PCMH) by the NCQA, the highest level of PCMH distinction possible demonstrating CSHC s commitment to innovative and patient-focused care.
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Experience with accreditation or regulatory audits, including NCQA, CMS audits. The Senior Compliance Analyst will be responsible for supporting the Compliance Officer in managing corporate compliance functions such as policy/procedure management, compliance hotline, conflict of interest, compliance training and regulatory change management.
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Experience in an MSO or ACO is preferred. Monitor the compliance hotline and compliance email address and work with the Compliance Officer to coordinate appropriate investigation and response to incoming reports.
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Coordinates all aspects of credentialing following NCQA and TDI requirements. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.
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Review conflict-of -interest disclosures and work with the Compliance Officer to investigate and manage reported conflicts. Support responding to external health plan audits of utilization management, claims, and credentialing operations, by completing audit questionnaires, submitting polices, and preparing operational records requested.
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ncqa job in Worcester, MA
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