Job ID: J119080
Company: Gateway Health Plan
Location: Wilmington, DE, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Apr 9, 2018
Description
GENERAL OVERVIEW:
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.
ESSENTIAL RESPONSIBILITIES:
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.
QUALIFICATIONS:
Minimum
Preferred
Knowledge, Skills and Abilities
WORK ENVIRONMENT
Is Travel Required?
Yes
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org
Interested in working at the Highmark Health enterprise?
Take the first step by joining our Talent Network today!