Gateway Health Plan
Job Description :
This job works with appropriate departments in the areas of compliance, process improvement and member/provider satisfaction for all product lines. Reviews, 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. Performs 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.
” Develop, manage process improvement initiatives from member/providers to include detailed data analysis, process analysis, report generation and documentation.
” 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.
” Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan.
” Conduct annual audits, identify gaps, communicate results and re-audit.
” Other duties as assigned or requested.
” Bachelor’s Degree in a Healthcare-related field or current state RN license
” 6 years of progressive Medical Coding experience
” 3-5 years of relevant, progressive experience in the area of specialization. Grandfathered experience requirements effective August 2016.
” 1 – 3 years of demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.)
” 1 – 3 years of prior project management experience preferred
” 1 – 2 years in Total Quality Management (TQM) concepts, techniques, process and outcome measurements
” 1 -2 years in Statistics in order to analyze various reports and validate study methodologies
LICENSES OR CERTIFICATIONS
” Current state RN license or Bachelor’s Degree in a Healthcare-related field
” Excellent verbal communication skills and professional manner, excellent written communication skills and a familiarity with a variety of writing styles. Must be able to communicate with medical administrators, including Medical Directors and Physician Advisors related to problem identification, action plan implementation, ongoing monitoring and problem resolution
” Well-developed, analytical and problem solving skills with the ability to understand and interpret clinical data
Language (other than English)
0% – 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Does Not Apply
Works primarily out-of-the office selling products/services (sales employees)
Does Not Apply
Physical work site required
Lifting: up to 10 pounds
Lifting up to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
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.
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