Provider Qualifications Specialist

Description

Central Coast Salary Range: $58,647 - $82,105

Job Summary

Reporting to the Provider Qualifications Supervisor, this position plays a pivotal role in facilitating the Facility Site Review (FSR), Medical Record Review (MRR), PARS and Credentialing processes that ensure compliance with regulatory requirements as well as enhance the quality of our provider network.

1. Coordination of Facility Site Review (FSR), Medical Record Review (MRR), and Physical Accessibility Review Surveys (PARs) processes to ensure compliance with regulatory requirements

2. Completion of gathering, reporting, verification, and auditing of provider qualifications and data across multiple platforms to support provider quality and data integrity

3. Monitoring of provider requirements and escalation of non-compliance, following established processes

4. Support special projects related to provider quality and qualifications

5. Other duties as assigned

Duties and Responsibilities

1. Coordination of Facility Site Review (FSR) and Medical Record Review (MRR) processes to ensure compliance with regulatory requirements

• Prepare and coordinate audits using the Department of Health Care Services (DHCS) FSR and MRR tools

• Schedule audit dates in compliance with both internal and regulatory standards and ensuring all necessary documentation is prepared and available

• Prepare, organize, update, and ensue all pre-site review and post site review educational materials are available to providers

• Serve as the point of contact for communication between the Provider Qualifications Supervisor, Quality Management Coordinator, internal teams, and external provider sites

• Monitor audit timelines and escalate any issues to leadership

• Collaborate with Provider Qualifications Supervisor and Quality Management Coordinator to effect process improvements in alignment with department goals

• Maintain accurate and organized records of all site visits, findings, and communications

• Track and document all Corrective Action Plans (CAPs) issued because of site reviews

• Prepare documentation and participate in special projects and assignments

• Ensure timely follow-up with providers for necessary corrections

• Conduct PAR assessments at providers sites utilizing the appropriate DHCS tool.

• Document PARs findings and assisting in providing feedback to enhance accessibility for members

• Collaborate with Quality Management Coordinator to support recommendations to providers and providing educational information

• Ensure PARs data is entered into provider data systems and accurately reflected in the Provider Directory

2. Completion of gathering, reporting, verification, and auditing of provider qualifications and data across multiple platforms to support provider quality and data integrity

• Ensure timely entry of provider data obtained through FSR/MRR/PARS and credentialing into Provider Data systems

• Produce reports on upcoming site visits and credentialing deadlines

• Support auditing efforts to ensure compliance with regulatory standards

• Assist with special projects and assignments related to credentialing, FSR/MRR and provider data management

• Prepare and submit FSR/MRR/PARS reports prior to regulatory submission

• Complete batch verification pulls in support of the credentialing and recredentialing processes

• Assisting with audits of FSR/MRR/PARS data between systems to ensure integrity

• Prepare internal audits of MSR/MRR/and PARS

• Gathering and verifying provider qualifications for credentialing cycles

• Monitoring and reporting on provider qualifications between recredentialing cycles

1. Monitoring of provider requirements and escalation of non-compliance, following established processes

• Identify and document instances of non-compliance related to provider requirements, such as recredentialing, site review completion, or Medi-Cal enrollment, ensuring accurate and detailed records

• Communicate non-compliance issues to providers and aid resolve corrective actions

• Escalate unresolved compliance issues to leadership in accordance with established protocols

• Maintain accurate records of non-compliance, and track provider progress towards mitigation

• Monitor the progress of mitigations to ensure timely resolution

3. Support special projects related to provider quality and qualifications

• Assist in the development and implementation of initiatives aimed at improving credentialing, FSR/MRR, and provider qualifications processes

• Lead special projects, as assigned

• Prepare reports and presentations summarizing project findings and recommendations

• Contribute to the development and refinement of policies and procedures related to provider credentialing and FSR/MRR

4. Other duties as assigned

Qualifications

Knowledge/Skills/Abilities:

Required:

• Understanding of NCQA, DHCS, and CMA regulations, and other relevant healthcare compliance requirements.

• Some knowledge of credentialing and recredentialing procedures.

• Knowledge of reporting methodologies and data analysis techniques used in the healthcare industry.

• Strong attention to detail in reviewing applications, reports, and documentation to ensure accuracy and compliance.

• Excellent verbal and written communication skills to convey information clearly and effectively to stakeholders at all levels.

• Proficiency in data management and reporting tools.

• Strong organizational abilities to manage multiple tasks, prioritize effectively, and meet deadlines in a fast-paced environment.

• Strong interpersonal skills to work effectively with cross-functional teams and build positive relationships with stakeholders.

• Flexibility to adapt to changing regulations, policies, and procedures in the healthcare landscape.

• Ability to use good judgement in making decisions within scope of authority and handle sensitive issues with tact and diplomacy.

• Ability to process a high volume of work and assume special projects over and above assigned responsibilities.

• Proficiency in Microsoft Office and virtual platforms

Education and Experience:

• Bachelor’s degree in healthcare, public health, or a related field and a minimum of three (3) years’ experience in managed health care or provider setting, or a qualifying combination of relevant education and professional experience

• Some working with data management systems and reporting tools

Salary : $58,647 - $82,105