Specialist-Quality & Credentialing

About the role

Responsible to develop the annual Quality Improvement workplan, lead the Quality Improvement committee and manage the activities outlined in the program. Ensure the credentialing program is current and consistent with the organization's contractual obligations and regulatory requirements including delegated agreements. Organize and lead the Credentialing Committee meetings. Respond to and take the lead in the delegated audit process. Serve as the content expert in matters regarding quality improvement and provider credentialing. Perform credentialing verification activities to include organizational providers and on-site quality reviews, maintaining a structured and well-documented process. Serve as the primary contact for regulatory standard questions related to quality improvement and credentialing. Conduct the annual access & availability study as part of the organization's network development efforts. Serve as the primary contact with the CVO.

Responsibilities

• Implement the Quality Improvement Program and the Credentialing Program.
• Draft the annual Quality Improvement program, including the workplan to present to the Quality Improvement Committee for approval.
• Evaluate and revise the Quality Improvement program no less than annually and formulate QI activities for consideration.
• Work with members of the HP team, the Quality Improvement Committee and the Chairperson to achieve the tasks and objectives of the program.
• Coordinate the collection of data in response to the QI workplan or other identified need as requested by the Quality Improvement Committee or the Chairperson.
• Formulate the processes to facilitate review of activities such as workplans, worksheets, data collection forms, time lines, and summary forms.
• Prepare quarterly detailed reports of QI activity that demonstrate the progress and findings of studies under investigation for the QI Committee.
• Update the credentialing program no less than annually and prepare recommendations for approval to the credentialing committee.
• Update the policy and procedure manual that governs the quality improvement and credentialing activities to ensure they accurately reflect responsibilities.
• Maintain working files in an organized secure fashion.
• Contribute to the productive and effective operation of Quality Improvement.
• Maintain a defined process for conducting, evaluating and reporting on-site quality assessments.
• Monitor grievances recorded on the grievance tracking system to ensure resolution and to identify issues that may need to be resolved.
• Evaluate and recommend a member satisfaction survey tool to be utilized for the HP population.
• Manage the distribution, tabulation, communication and follow-up activity regarding the satisfaction tool.
• Manage the administration of the patient satisfaction survey in accordance with the QI workplan.
• Contribute to the productive and effective operation of Credentialing.
• Ensure compliance with NCQA credentialing standards to maintain certification by way of audit and oversight.
• Prepare the NCQA re-certification application in a timely fashion.
• Lead the on-site review process.
• Convey results and opportunities for improvement.
• Evaluate credentialing procedures in accordance with the workplan or as deemed necessary to address areas of potential risk.
• Conduct a final review of credentials files, using the approved data collection tools, prior to consideration by the Credentials Committee.
• Credential 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.
• Maintain and update the provider e-directory.
• Process annual provider network participation fees.
• Maintain an organized provider file including all necessary information outlined in the Credentialing Program.
• Promote and contribute to achieving quality service.
• Follow the needs assessment process in determining facility eligibility and communicate findings to management according to policy.
• Prepare the annual access and availability study as part of the organization's network development efforts.
• Respond to provider issues and member problems and questions in a timely fashion.
• Coordinate the activities required to successfully achieve external accreditation with NCQA.
• Provide in-services for providers and HP staff to promote education.
• Lead and/or participate in other committees as assigned.
• Collaborate with NGHS Quality Improvement, Risk Management and Infection Control personnel as needed.
• Participate in organizational wide education efforts to promote QI and patient satisfaction expectations.

Qualifications

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

Skills

• 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 NCQAKnowledge of various computer programs such as Word and Excel

Benefits

Northeast Georgia Health System offers a comprehensive benefits package designed to support you and your family. This includes medical, dental, vision, life insurance, disability, and retirement plans. For more details, please refer to the Employee Handbook.

Pay

The salary range for this position is $XX.XX - $XXXX.XX per year, based on qualifications and experience. The actual salary offered will be determined during the hiring process.

Schedule

This position is available on an 8-hour morning-afternoon shift.