Quality​/Clinical Coordinator

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing whole-person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 6,000 health care providers, including primary and specialty care physicians, hospitals and ancillary providers. We have operated in the Arizona market for more than 12 years, based in Chandler, Arizona, and are an affiliate of Heritage Provider Network.

As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.

The Quality/Clinical Coordinator is responsible for assisting with the administrative and operational functions within the Clinical Services department. This includes divisions such as Utilization Management (UM), Credentialing (CR) and Quality (QI) activities. Specific responsibilities include Health Plan interactions such as UM/CR reporting, audits, member Appeals/Grievances, Provider/Member Surveys, record keeping and project management. This position will report directly to the Director, Clinical Services Operations.

POSITION DUTIES & RESPONSIBILITES

Prior Auth & Credentialing

• Review weekly, monthly, quarterly, and annual health plan reports for errors and compliance issues. Make necessary corrections and submit them to the health plan on behalf of the Director.
• Assist in pre- and post-committee tasks for bi-monthly and quarterly UM & CR Committee meetings. This includes creating agendas, sending meeting invites, confirming attendance, check requests, taking meeting minutes, finalizing documents, and notifying department heads.
• Assist in obtaining Annual Confidentiality Statements for both internal and external committee members, including new members as necessary.
• Generate monthly reports for auditing prior authorization and credentialing staff and notify the Credentialing Lead and Director.
• Serves as a secondary contact with regulatory agencies for reporting requirements and ensures ongoing compliance is met with regulatory and accreditation agencies including, but not limited to, CMS, NCQA and contracted health plans.
• Collaborates with Director regarding identified opportunities for improvement and ensure implementation of all necessary
• Other duties or special projects as

Quality

• Ensure proper processing of initial receipt, entry and investigation of Appeal/Grievance cases, including appropriate medical record requests and professional inquiries.
• Ensure professional response letters to health plans, summarizing AZPC findings and actions.
• Ensure maintenance of accurate databases for statistics reporting, case tracking and health plan turnaround compliance.
• Participate with PCP/staff education, regarding Appeals & Grievances and request CAP.
• Assist in pre- and post-committee tasks for quarterly Quality Improvement Committee (QIC) meetings. This includes creating agendas, taking meeting minutes, finalizing documents, and notifying department heads.
• Assist in QI work plan initiatives and activities.
• Assist in preparation of audit files for the NCQA accreditation and Health Plan audits.
• Complete spreadsheets and audit tools for various Quality activities, as well as necessary revisions to tools.
• Help create various reports, audit tools, and training materials.
• Collaborate with management on the creation of new QI SOPs and annual review, thereafter, ensuring notification of new or updated P&P’s are presented at appropriate UM/QI Committee.
• Assist with conducting member satisfaction surveys, data entry of results and submission of initial summary of findings to Director.
• Assist with collecting medical records and other pertinent documentation.
• Ensure scanning has been completed for Appeal/Grievances and other QI case files into electronic storage system.

EDUCATION, TRAINING AND EXPERIENCE

• Associate degree in any field in healthcare, required
• Prior experience in the medical field, with proficient knowledge of medical terminology and data entry; physician front office experience preferred.
• Minimum of 3 years healthcare administrative experience with demonstrated excellent communication, attention to detail and problem-solving skills.
• Demonstrated knowledge of managed care systems, NCQA, and CMS standards for Credentialing & Utilization Management.
• Excellent knowledge of computer application, including Work, Excel, Outlook, and Power Point.
• Demonstrates exceptional time management and organizational
• Demonstrated excellent customer service etiquette skills, orally and in
• Demonstrated ability to work within a team environment and creatively to achieve organizational goals.
• Driving occasionally required, current and unrestricted AZ driver license with proof of insurance required.
• Ability to work independently with minimum supervision.

* This role requires 60 days FT in office presence, hybrid options will be available after the 60-day period.*