Accreditation Quality & URL Specialist II

MedImpact•San Diego, CA

5d•Onsite

About The Position

Responsible for the execution of the annual accreditation, clinical quality, and UR licensure assessment processes and work plans required to obtain and maintain MedImpact's NCQA and URAC accreditations and state UR licensure requirements across all lines of business, including Commercial, Medicare, Medicaid, and Marketplace. Applies healthcare and clinical quality expertise to accreditation readiness, delegation oversight, committee support, and ongoing quality monitoring activities. Coordinates with internal partners, delegated entities, and client-facing teams to accomplish assigned accreditation, clinical quality, and compliance activities.

Requirements

BS/BA and 5+ years’ experience or equivalent combination of education and experience, and 3 years of SME within a PBM, Managed Care, provider setting in addition to direct experience in clinical quality, utilization management or accreditation.
Demonstrated subject-matter expertise with NCQA and/or URAC standards, including survey preparation, evidence and documentation development, and file review, is required.
Microsoft Office Suite (Word/Excel/Access/Outlook),Teams and standard PDF document tools, including the ability to create, combine, annotate, and complete fillable PDF documents.
An unencumbered healthcare related license is required. Examples of applicable licenses include Pharmacy Technician (CPT), Medical Assistant (MA), and/or Registered Nurse (RN).
Demonstrated experience leading operational projects from inception to completion, ensuring objectives, timelines, and deliverables are achieved.
Ability to collect and analyze requirements while creating and managing detailed project plans to support accreditation and quality management activities.
Excellent interpersonal and relationship-building skills, with the ability to contribute independently and within a team environment.
Proven flexibility and adaptability in responding to changing deliverables, priorities, and timelines.
Working knowledge of prior authorization, appeals, and utilization management processes, including applicable federal and state regulatory requirements.
Strong written and verbal communication skills, including preparation of audit findings, committee materials, and client-facing documentation.
Experience managing competing priorities and concurrent workstreams related to accreditation, licensure, and audits while ensuring accuracy, compliance, and timely completion, with minimal supervision.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to read, analyze, and interpret the most complex documents.
Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Composure
Decision Quality
Organizational Agility
Problem Solving
Customer Focus
Drive for Results
Peer Relations
Time Management
Dealing with Ambiguity
Learning on the Fly
Political Savvy

Nice To Haves

Direct experience working with URAC Pharmacy Benefit Management (PBM) accreditation standards is highly preferred.
Working knowledge of enterprise document management, prior authorization, appeals, and quality reporting systems is preferred.
Healthcare quality or accreditation-related certification, such as Certified Professional in Healthcare Quality (CPHQ), is preferred.

Responsibilities

Performs accreditation, quality, and utilization management related audits and activities with an emphasis on obtaining or maintaining NCQA and URAC accreditation and multi-state UR licensure.
Participates in onsite audits/reviews, agency inquiries, and training employees, as needed.
Supports responses to accreditor, regulator, and client audits, inquiries, and documentation requests.
Performs ongoing monitoring to ensure the organization is meeting accreditation, regulatory, and contractual standards.
Analyzes data, case files, workflows, policies and procedures to assess program effectiveness.
Interprets significance of routine-intermediate findings to identify areas of improvement, make and implement recommendations for improvement, and track corrective actions to closure.
Defines and documents accreditation and compliance process steps (i.e., policy and procedures) in accordance with current state, federal, and independent accreditation and UR licensing requirements.
Maintains assigned policies and procedures within the enterprise document management system in accordance with annual review requirements.
Communicates and consults with internal partners, delegated entities, and client-facing teams to assist with the implementation of accreditation, clinical quality, and compliance recommendations for assigned area(s).
Serves as accreditation subject-matter expert for NCQA and/or URAC standards and for all or specific program sections, to consult and update internal partners on accreditation efforts and requirements.
May recommend and provide training to employees regarding accreditation and compliance requirements and procedures.
Stays current with accreditation standard updates, state legislative activity, and regulatory requirements, as well as PA/UM and Appeals programs to consult and provide a mutually beneficial resolution.
Performs pre-delegation evaluations and supports ongoing delegation oversight activities, including annual delegate monitoring and review of delegation agreements and responsibility matrices against currently applicable accreditation standards.
Prepares accreditation, clinical quality, and utilization management reporting for quality and utilization management oversight committees, including agendas, materials, minutes, and tracking of assigned action items through closure.
Supports client-facing accreditation and quality deliverables, including requests for proposal (RFP) responses, delegation agreement inquiries, and client audit support, in coordination with account management.
Serves as a primary departmental resource for URAC Pharmacy Benefit Management accreditation requirements, including evidence development, annual and interim reporting, and ongoing compliance monitoring.
Other duties as assigned.