Specialist-Quality & Credentialing

Job Category:
Administrative & Clerical Work Shift/

Schedule:

8 Hr Morning - Afternoon Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

Job Summary 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.

Licensure or other certifications:

Educational Requirements:

Bachelors Degree or equivalent with six (6) to eight (8) years of relevant experience.

Minimum Experience:

Minimum of six (6) years experience in a large group practice or managed care setting responsible for Quality Improvement and credentialing activities. Other:
Preferred Job Qualifications Preferred Licensure or other certifications:
Preferred

Educational Requirements:

Preferred Experience:

Other:

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

• Responsible for implementing the Quality Improvement Program and the Credentialing Program.
• Drafts the annual Quality Improvement program, including the workplan to present to the Quality Improvement Committee for approval.
• Evaluates and revises the Quality Improvement program no less than annually and formulates QI activities for consideration.
• Works with members of the HP team, the Quality Improvement Committee and the Chairperson to achieve the tasks and objectives of the program.
• Coordinates the collection of data in response to the QI workplan or other identified need as requested by the Quality Improvement Committee or the Chairperson.
• Formulates the processes to facilitate review of activities such as workplans, worksheets, data collection forms, time lines, and summary forms.
• Prepares quarterly detailed reports of QI activity that demonstrate the progress and findings of studies under investigation for the QI Committee.
• Updates the credentialing program no less than annually and prepares recommendations for approval to the credentialing committee.
• Updates the policy and procedure manual that governs the quality improvement and credentialing activities to ensure they accurately reflect responsibilities.
• Maintains working files in an organized secure fashion.
• Contributes to the productive and effective operation of Quality Improvement.
• Arranges site visits to provider offices to perform quality assessments as defined in the QI program.
• Maintains a defined process for conducting, evaluating and reporting on-site quality assessments.
• Monitors grievances recorded on the…