Specialist-Quality & Credentialing — Gainesville, GA

Job Category:

Administrative & Clerical

Work Shift/Schedule:

8 Hr Morning - Afternoon

About the Role

Job Summary

Responsible to develop the annual Quality Improvement workplan, lead the Quality Improvement committee and manage the activities outlined in the program. Shall ensure the credentialing program is current and consistent with the organization's contractual obligations and regulatory requirements including delegated agreements. Shall organize and lead the Credentialing Committee meetings. Responsible to respond to and take the lead in the delegated audit process. Shall serve as the content expert in matters regarding quality improvement and provider credentialing. Shall perform credentialing verification activities to include organizational providers and on-site quality reviews, maintaining a structured and well-documented process. Shall be the primary contact for regulatory standard questions related to quality improvement and credentialing. Shall conduct the annual access & availability study as part of the organization's network development efforts. Shall be the primary contact with the CVO. Shall utilize effective problem solving skills to resolve performance issues.

Minimum Job Qualifications

• Licensure or other certifications:
• Educational Requirements: Bachelors Degree or equivalent with six (6) to eight (8) years of relevant experience.
• Minimum Experience: Minimum of six (6) years experience in a large group practice or managed care setting responsible for Quality Improvement and credentialing activities.
• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:
• Preferred Educational Requirements:
• Preferred Experience:
• Other:

• Assessment and problem solving skills
• Detail and deadline oriented with strong follow-up skills
• Organized
• Effective verbal and written communication skills
• Knowledge of the regulatory standards of JCAHO for PPOs, URAC and NCQA
• Knowledge of various computer programs such as Word and Excel

Essential Tasks and Responsibilities

• Responsible for implementing the Quality Improvement Program and the Credentialing Program. Drafts the annual Quality Improvement program, including the workplan to present to the Quality Improvement Committee for approval. Evaluates and revises the Quality Improvement program no less than annually and formulates QI activities for consideration. Works with members of the HP team, the Quality Improvement Committee and the Chairperson to achieve the tasks and objectives of the program. Coordinates the collection of data in response to the QI workplan or other identified need as requested by the Quality Improvement Committee or the Chairperson. Formulates the processes to facilitate review of activities such as workplans, worksheets, data collection forms, time lines, and summary forms. Prepares quarterly detailed reports of QI activity that demonstrate the progress and findings of studies under investigation for the QI Committee. Updates the credentialing program no less than annually and prepares recommendations for approval to the credentialing committee. Updates the policy and procedure manual that governs the quality improvement and credentialing activities to ensure they accurately reflect responsibilities. Maintains working files in an organized secure fashion.
• Contributes to the productive and effective operation of Quality Improvement. Arranges site visits to provider offices to perform quality assessments as defined in the QI program. Maintains a defined process for conducting, evaluating and reporting on-site quality assessments. Monitors grievances recorded on the grievance tracking system to ensure resolution and to identify issues that may need to be resolved. Ensures that patient satisfaction issues are investigated, resolved and reported to the QI committee. Evaluates and recommends a member satisfaction survey tool to be utilized for the HP population. Shall manage the distribution, tabulation, communication and follow-up activity regarding the satisfaction tool. Manages the administration of the patient satisfaction survey in accordance with the QI workplan.
• Contributes to the productive and effective operation of Credentialing. Responsible to ensure compliance with NCQA credentialing standards to maintain certification by way of audit and oversight. Shall prepare the NCQA re-certification application in a timely fashion. Leads the on-site review process. Conveys results and opportunities for improvement. Evaluates credentialing procedures in accordance with the workplan or as deemed necessary to address areas of potential risk. Responsible to conduct a final review of credentials files, using the approved data collection tools, prior to consideration by the Credentials Committee. Oversees the credentialing of providers through primary source verification as outlined in the credentialing program. Maintains compliance with delegated credentialing agreements to include, but not limited to, preparing quarterly and annual metrics and performance reports for no less than nine delegated agreements. Requests contractual amendments for changes. Credentials all facilities interested in participating with HP according to the Credentialing Program in order to present them to the Credentialing Committee for review and approval or disapproval. Maintains and updates the provider e-directory. Responsible for invoicing and processing of annual provider network participation fees. Maintains an organized provider file including all necessary information outlined in the Credentialing Program.
• Promotes and contributes to achieving quality service. Follows the needs assessment process in determining facility eligibility and communicates findings to management according to policy. Shall prepare the annual access and availability study as part of the organizations network development efforts. Responds to provider issues and member problems and questions in a timely fashion. Coordinates the activities required to successfully achieve external accreditation with NCQA. Provides in-services for providers and HP staff to promote education. Leads and/or participates in other committees as assigned. Collaborates with NGHS Quality Improvement, Risk Management and Infection Control personnel as needed. Participates in organizational wide education efforts to promote QI and patient satisfaction expectations.

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time
• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time
• Vision: Heavy, Constantly 66-100% of time
• Kneeling/Stooping/Bending: Occasionally 0-30%
• Standing/Walking: Occasionally 0-30%
• Pushing/Pulling: Occasionally 0-30%
• Intensity of Work: Occasionally 0-30%
• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

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