Specialist-Quality & Credentialing

Northeast Georgia Health System•Gainesville, GA

11d•Onsite

About The Position

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.

Requirements

Bachelors Degree or equivalent with six (6) to eight (8) years of relevant experience.
Minimum of six (6) years experience in a large group practice or managed care setting responsible for Quality Improvement and credentialing activities.
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

Responsibilities

Implementing the Quality Improvement Program and the Credentialing Program.
Drafting the annual Quality Improvement program, including the workplan to present to the Quality Improvement Committee for approval.
Evaluating and revising the Quality Improvement program no less than annually and formulating QI activities for consideration.
Coordinating the collection of data in response to the QI workplan or other identified need as requested by the Quality Improvement Committee or the Chairperson.
Formulating the processes to facilitate review of activities such as workplans, worksheets, data collection forms, time lines, and summary forms.
Preparing quarterly detailed reports of QI activity that demonstrate the progress and findings of studies under investigation for the QI Committee.
Updating the credentialing program no less than annually and preparing recommendations for approval to the credentialing committee.
Updating the policy and procedure manual that governs the quality improvement and credentialing activities to ensure they accurately reflect responsibilities.
Maintaining working files in an organized secure fashion.
Arranging site visits to provider offices to perform quality assessments as defined in the QI program.
Maintaining a defined process for conducting, evaluating and reporting on-site quality assessments.
Monitoring grievances recorded on the grievance tracking system to ensure resolution and to identify issues that may need to be resolved.
Ensuring that patient satisfaction issues are investigated, resolved and reported to the QI committee.
Evaluating and recommending a member satisfaction survey tool to be utilized for the HP population.
Managing the distribution, tabulation, communication and follow-up activity regarding the satisfaction tool.
Managing the administration of the patient satisfaction survey in accordance with the QI workplan.
Ensuring compliance with NCQA credentialing standards to maintain certification by way of audit and oversight.
Preparing the NCQA re-certification application in a timely fashion.
Leading the on-site review process.
Conveying results and opportunities for improvement.
Evaluating credentialing procedures in accordance with the workplan or as deemed necessary to address areas of potential risk.
Conducting a final review of credentials files, using the approved data collection tools, prior to consideration by the Credentials Committee.
Overseeing the credentialing of providers through primary source verification as outlined in the credentialing program.
Maintaining 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.
Requesting contractual amendments for changes.
Credentialing 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.
Maintaining and updating the provider e-directory.
Invoicing and processing of annual provider network participation fees.
Maintaining an organized provider file including all necessary information outlined in the Credentialing Program.
Following the needs assessment process in determining facility eligibility and communicating findings to management according to policy.
Preparing the annual access and availability study as part of the organizations network development efforts.
Responding to provider issues and member problems and questions in a timely fashion.
Coordinating the activities required to successfully achieve external accreditation with NCQA.
Providing in-services for providers and HP staff to promote education.
Leading and/or participating in other committees as assigned.
Collaborating with NGHS Quality Improvement, Risk Management and Infection Control personnel as needed.
Participating in organizational wide education efforts to promote QI and patient satisfaction expectations.