NCQA Accreditation Compliance Specialist

Summary
 Responsible for leading accreditation compliance activities to include interpretation of the standards, monitoring of multiple areas' compliance, providing guidance to management and associates on compliance issues.
This position involves working closely with cross-functional teams to ensure that accreditation efforts are successfully executed, monitored, and maintained. The analyst will track, analyze, and report on accreditation-related activities and requirements, helping the organization maintain high standards of care and compliance.
Description
 

Location:

This position is HYBRID/REMOTE in South Carolina, North Carolina, or Georgia as travel to Columbia, SC one (1) day per week is required. This position is full-time (40-hours/week) Monday-Friday. Please note this is subject to change based off of employee performance and/or business need.

What You’ll Do:

• Lead accreditation compliance activities including review and interpretation of the standards, monitoring of multiple areas' compliance, as well as developing and implementing quality improvement activities to improve compliance.

• Responsible for maintaining full three-year accreditation status and monitoring National Committee for Quality Assurance (NCQA) accreditation processes/standards.

• Conduct/participate in audits of areas, such as member services and utilization management, to ensure compliance with NCQA activities or to assess service issues.

• Analyze audit results, makes appropriate recommendations for changes to improve compliance or level of service, works with the other departments to prepare a corrective action plan, prepares formal documentation of the audit, and monitors ongoing corrective action plan to ensure recommendations are being implemented.

• Lead Quality Improvement and Accreditation System (QIAS) activities including specific responsibilities for some of the QIAS as well as oversight and review of all QIAS to ensure compliance with NCQA standards.

• Conduct analysis of quality improvement activity findings, makes recommendations for corrective actions, prepare formal documentation of activities, present findings to relevant committees, and monitor corrective action plan to ensure recommended actions are being taken.

• Perform compliance analysis and informs management of any changes.

• Responsible for the reporting of quality of care.

• Responsible for providing Health Plan Employee Data and Information Set (HEDIS) support for multiple departments.

• Monitors HEDIS and informs appropriate management and QI staff of any changes. Also coordinate the preparation of on-site audits conducted by external bodies.

• Develop special coding plan for HEDIS and Accreditation initiatives.

• Review medical records to perform a variety of coding validations for multiple lines of business to monitor the appropriateness of medical care and determine accuracy of billing and payment.

• Research and monitors CMS rules and regulations around HEDIS, Stars and Risk.

• Lead special accreditation/HEDIS projects/activities, as assigned by management, including but not limited to: conducting clinical studies; performing quality of service reviews, including tracking, trending, and profiling; investigating quality of service complaints taking necessary actions to improve clinical and service performance. Coordinating committee meetings and prepares committee minutes.

To Qualify for This Position, You'll Need the Following:

• Required Education:  Bachelor's in a job related field

• Required Work Experience: 5 years of health insurance industry, audit/compliance/investigations, project management, or corporate level related experience. If Master’s degree, required work experience is 3 years.

• Required Skills and Abilities:

  • Ability to effectively communicate both verbal and in writing to all levels of the organization.

  • Knowledge/understanding of medical terminology and medical coding.

  • Excellent analytical or critical thinking and problem solving skills.

  • Ability to make sound decisions and work independently.

  • Ability to exercise confidentiality and discretion.

  • Excellent presentation skills with strong attention to detail.

• Required Software and Tools: Microsoft Office skills

• Work Environment: Typical office environment.

We Prefer That You Have the Following:

• NCQA Experience is STRONGLY PREFERRED.

Our comprehensive benefits package includes the following:

We offer our employees great benefits and rewards.  You will be eligible to participate in the benefits the first of the month following 28 days of employment.  

• Subsidized health plans, dental and vision coverage

• 401k retirement savings plan with company match

• Life Insurance

• Paid Time Off (PTO)

• On-site cafeterias and fitness centers in major locations

• Education Assistance

• Service Recognition

• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

What to Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Management will be conducting interviews with those candidates who are the most qualified, with prioritization given to those candidates who demonstrate the required qualifications.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email [email protected] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information.

Some states have required notifications. Here's more information.