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, and Georgia. You will be required to come into the office in Columbia, SC 1 day per week. 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