Job ID: J116043
Company: Gateway Health Plan
Location: Home, WV, United States
Facility: Work From Home
Full/Part Time: Full time
Job Type: Regular
Responsible for working with appropriate departments in the areas of compliance, process improvement and member/provider satisfaction for all product lines. Review, researches and responds to customer complaints relating to quality of medical care and service. Recommends and/or implements process improvements related to the potential of quality medical care and service. Serves as a resource regarding accreditation standards including NCQA standards and continuous quality improvement principles. May coordinate accreditation activities on behalf of the organization. Perform special studies per audits, conducting office site visits and medical records reviews, ensuring resolution of member/provider complaints in timely manner. Coordinating credentialing and re-credentialing activities to include QM information, and support preparations for regulatory audits.
1. Develops, manages process improvement initiatives from member/providers to include detailed data analysis, process analysis, report generation and documentation.
2. Conduct, collect and analyze data from office site and/or medical record reviews to continually improve the care and service to members and coordination with the credentialing and quality improvement programs to achieve and maintain accreditation.
3. Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan.
4. Conduct annual audits, identify gaps, communicate results and re-audit
5. Other duties as assigned or requested.
Education, Licenses/Certifications, and Experience
Additional relevant knowledge and/or skills and/or work experience:
Knowledge, Skills and Abilities
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
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