Omaha, Nebraska
Quality Management Review Specialist Job Opening in Omaha, Nebraska - General Summary:
The QM Review Specialist is responsible for oversight and management of the delegated credentialing organizations that delegate credentialing duties to us and to which we delegate credentialing authority. This includes pre-assessment, annual evaluation, onsite review, monitoring, and responding to requests for desk top review. Responsible for reporting and recording credentialing quality program statistics and project updates. Updates department policies and procedures and the Credentialing Plan as required by national credentialing standards. Objectively and systemically monitors and evaluates the quality of care and services provided to healthcare plan members.
Acts as the point of contact for delegated credentialing organizations. Performs annual oversight of delegated credentialing organizations to include policy/procedure review, credentialing file audits, reporting to Membership Committee, tracking of deficiencies and process improvement, semi-annual reporting. Conducts onsite surveys of each entity that performs credentialing functions at least every three (3) years. Responds to requests for delegated credentialing audits by organizations that delegate the credentialing responsibility to Midlands Choice, and generate quarterly and semi-annual reporting for those organizations. (30%)
Develops standards and policies and procedures for quality management. Assists with development, processing and reporting of ongoing credentialing quality improvement projects, and quarterly and year-end quality management reporting. (10%)
Monitors NCQA and URAC websites for updates and changes to credentialing standards and assists Manager to update policies/procedures and the Credentialing Plan as necessary. Participates in the organization and completion of URAC accreditation applications, audits and onsite reviews. (15%)
Assists with monitoring the automatic customer service system, assigns cases to department members, and responds to general and status credentialing questions. (10%).
Researches, evaluates, and resolves credentialing database issues which are elevated by the database coordinators. (5%)
Investigates and responds to member complaints related to quality of care. (10%)
Reviews and maintains office site and medical record review criteria to comply with URAC, NCQA and regulatory requirements. Responsibilities to include updating website data, publishing criteria annually in the provider newsletter and contacting new offices regarding onsite/medical record criteria, when appropriate, to capitalize on educational opportunities. (5%)
Provides research on new processes, procedures, or complex cases. Assists with training when necessary. (15%)
Knowledge, Skills, and Abilities:
Knowledge of managed healthcare policies and procedures, including PPO practices.
Knowledge of URAC and NCQA Standards as applicable to credentialing, quality management and onsite and medical record review processes. Written operational policies and procedures as appropriate to the job are provided during department training and as standards are revised.
Knowledge of quality assurance/quality improvement principles.
Knowledge of medical terminology and processes.
Knowledge of general coding practices and processes.
Skill in oral and written communication.
Skill in the operation of office equipment including personal computer or laptop computer, relevant software, printer, facsimile machine, copy machine, and telephone system.
Ability to communicate with supervisors, co-workers, and various business contacts in a professional, courteous, and congenial manner.
Ability to organize, prioritize, and handle multiple work assignments.
Ability to work independent of supervision maintaining high level of self-motivation.
Ability to travel (10%)
Education and Experience:
Registered Nurse with Nebraska and/or Iowa Licensure, or Certified CPCS preferred, plus 2 years managed healthcare experience.
Job Type: Full-time
Required experience:
healthcare: 2 years
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