Exemption Status:
United States of America (Exempt)
$68,571 - $93,600 - $118,628
“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”
This position is not eligible for Sponsorship.
MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!
Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.
At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!
Job Description
Summary
Responsible for the execution of the annual accreditation, clinical quality, and UR licensure assessment processes and work plans required to obtain and maintain MedImpact's NCQA and URAC accreditations and state UR licensure requirements across all lines of business, including Commercial, Medicare, Medicaid, and Marketplace. Applies healthcare and clinical quality expertise to accreditation readiness, delegation oversight, committee support, and ongoing quality monitoring activities. Coordinates with internal partners, delegated entities, and client-facing teams to accomplish assigned accreditation, clinical quality, and compliance activities.
Essential Duties and Responsibilities include the following. Other duties may be assigned.
Performs accreditation, quality, and utilization management related audits and activities with an emphasis on obtaining or maintaining NCQA and URAC accreditation and multi-state UR licensure.
Participates in onsite audits/reviews, agency inquiries, and training employees, as needed. Supports responses to accreditor, regulator, and client audits, inquiries, and documentation requests. Performs ongoing monitoring to ensure the organization is meeting accreditation, regulatory, and contractual standards.
Analyzes data, case files, workflows, policies and procedures to assess program effectiveness. Interprets significance of routine-intermediate findings to identify areas of improvement, make and implement recommendations for improvement, and track corrective actions to closure.
Defines and documents accreditation and compliance process steps (i.e., policy and procedures) in accordance with current state, federal, and independent accreditation and UR licensing requirements. Maintains assigned policies and procedures within the enterprise document management system in accordance with annual review requirements.
Communicates and consults with internal partners, delegated entities, and client-facing teams to assist with the implementation of accreditation, clinical quality, and compliance recommendations for assigned area(s).
Serves as accreditation subject-matter expert for NCQA and/or URAC standards and for all or specific program sections, to consult and update internal partners on accreditation efforts and requirements. May recommend and provide training to employees regarding accreditation and compliance requirements and procedures.
Stays current with accreditation standard updates, state legislative activity, and regulatory requirements, as well as PA/UM and Appeals programs to consult and provide a mutually…