Quality Accreditation Coordinator

Position Summary

The Quality and Accreditation Coordinator supports the organization's quality improvement, regulatory compliance, and NCQA accreditation activities. This role is responsible for assisting the Director of Quality Operations in coordinating quality programs, monitoring performance measures, supporting NCQA health plan accreditation surveys, maintaining required documentation, and collaborating with internal departments to ensure compliance with federal, state, and NCQA health plan accreditation standards. The coordinator assists in driving continuous quality improvement initiatives that improve member outcomes, operational performance, and health plan effectiveness.

Essential Duties And Responsibilities

• Review and analyze data across various areas, including claims, authorizations, grievances, appeals, case management, network adequacy, membership composition, and other related fields.
• Aid with QOC investigation, QIC Prep, monitoring, and auditing.
• Support with preparation of evidence files and documentation for NCQA health plan accreditation surveys.
• Collect reporting for measurement and benchmarking of performance measures in relation to best practices for NCQA, CMS, and internal business objectives.
• Ensure data is accurate, reliable, and reported timely.
• Collect performance indicator reports and benchmark narratives for review by Director of Quality Operations for performance improvement recommendations.
• Assist with monitoring quality performance, outcomes, and/or metrics to make recommendations for targeted process improvement projects.
• Prepare overviews and interpretation of reports; and follow up on assigned action items for various projects, meetings, and committees.
• Aid with accreditation and quality-related education to staff as needed.
• Aid with problem analysis for strategic planning initiatives.
• Solve data integrity issues as they arise, and monitor the addition of new data, analytics, and reporting systems.
• Aid with interpretation and translation of data for senior management for use in meaningful decision making, and strategic planning purposes.
• Aid with internal and external audits and preparation of audit responses.
• Collect supporting documentation to support review of Quality-of-Care concern investigations.

Qualifications And Education

• HS Diploma required or Associate's degree in Healthcare Administration, Nursing, or related field.
• 2+ years of experience in managed care, Medicare, Medicaid, or health plan setting.
• Bilingual in English and Spanish.
• Relevant experience may substitute for the educational requirement on a year-for-year basis.

Work Conditions

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• The noise level in the work environment is usually moderate.
• Fast-paced office environment.
• Highly regulated environment.
• Interacts with patients, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.
• This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity.
• The work schedule is approximate, and hours/days may change based on company needs.
• All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed.
• May require some OT during varying seasons of the year.

Physical Demands

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
• The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds.
• While performing the duties of this job, the employee is regularly required to talk or listen.
• The employee is frequently required to stand and walk.
• The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl.
• Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Performance Measurements

• Duties accomplished at the end of the day/month.
• Attendance/punctuality.
• Compliance with Company regulations.
• Safety and Security.
• Quality of work.