Manager of Quality and Accreditation

  • Full-time

Company Description

HealthHelp - A WNS Company (www.HealthHelp.com), is the leader in the field of healthcare utilization & care management. We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach. Our methodology helps payors achieve a higher return on investment, gives providers education programs that better inform physicians, and ensures quality and safety for the patients needing treatment.

HealthHelp’s innovative approach and strong IT capability in specialty benefits management means that staff will move healthcare forward when provided with evidence-based solutions and second opinions. HealthHelp's staff is comprised of healthcare professionals who make a difference every day. HealthHelp has a desire to fill their company with talented and innovative people who want a career path filled with success and personal growth.

Our specialty benefits management services are broad and include, Cardiology, Oncology, Radiology, Radiation Therapy, Sleep Care, and Musculoskeletal Care. HealthHelp has two locations in Houston, one a corporate office and the second a state-of-the art contact center. HealthHelp is also proud to have another such contact center in Albany, New York.

WNS (Holdings) Limited (NYSE: WNS) is a global Business Process Management (BPM) leader. WNS offers business value to 400+global clients by combining operational excellence with deep domain expertise in key industry verticals, including Banking and Financial Services, Consulting and Professional Services, Healthcare, Insurance, Manufacturing, Retail and Consumer Packaged Goods, Shipping and Logistics, Telecommunications, Travel and Utilities.

Job Description

The Manager of Quality and Accreditation is responsible for continuous quality improvement of clinical review function through oversight of the team responsible for audit, and working collaboratively with other departments to implement specific training initiatives and design/redesign of clinical processes. This position is expected to evolve into a Subject Matter Expert (SME) with a comprehensive understanding of CMS and all other applicable Regulatory Agencies / Accreditations and collaborates with the Chief Medical Officer/Compliance Officer/Privacy Officer, regarding CMS and all other applicable Regulatory Agencies/Accreditations.

This newly created position will support the Executive Director of Medical Operations/Quality in achieving the goals of the Quality Department through the following responsibilities.
Oversees all aspects of quality audit and credentialing programs
Develops and implements standardized processes for conducting quality audits of work performed by physician and clinical review staff, including IRR audits
Works in conjunction with Clinical Review and Medical Operations management to address areas of deficiency identified on quality audits
Conducts documentation and metrics reporting of all monthly and quarterly audit results by the 10th of the following month
Actively participates on Quality/Compliance Committee(s) per regulatory requirements
Reports quality audit data for Quality Management (QM) Committee meetings
Develops, maintains tracking logs for, and updates all records pertaining to mandatory education for new and existing employees, to meet regulatory agency and accreditation requirements
Adheres to all current HIPAA, FWA, Consumer Health and Safety, and state and federal regulations pertaining to the clinical programs
Initiates and maintains monthly tracking logs OIG and EPLS on all clinical staff per CMS guidelines
Assists with audit needs as requested by external auditors (clients, URAC, NCQA, etc.)
Oversees credentialing on all clinicians including, MD’s, RN’s, LVN’s, LPN’s, and any other licensed contractor or employee of HealthHelp according to company policies and procedures
Oversees the creation and maintenance of electronic and/or hard copy physical credentialing files, including tracking logs of licenses and AMA profiles
Oversees the investigation of reported complaints to attain resolution, ensuring the highest level of confidentiality while adhering to the formal complaint process
Reports complaint results to the QM Committee and to the respective health plans per contractual agreement
Develops reporting tools and metrics specific to established CQI, for monthly, quarterly, and annual tracking
Documents outcomes/results specific to contractual requirements per health plan and/or regulatory requirements
Works in conjunction with management to develop and implement strategies to meet/exceed organizational quality/compliance metrics
Monitors staff work assignments and makes appropriate adjustments based on staffing levels, proficiency, and workload
Tracks and monitors team performance, provides feedback
Develops and implements process improvement initiatives to increase operational efficiencies
Recognizes and informs management of critical issues
Adheres to all regulatory requirements and complies with HealthHelp policies and procedures
Upholds professional standards and performs all work in a manner respectful of others
Provides a high level of service and support to both internal and external clients
Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy
Performs other duties as assigned to meet business needs
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Qualifications

Graduate of an accredited school of nursing
Active, unrestricted RN license in a state or territory of the U.S. required with additional advanced qualification (e.g., BSN/MSN/BS or BA) preferred
Certified Professional in Health Care Quality (CPHQ) preferred
Experience and understanding of Quality Management Program requirements as defined by URAC, NCQA, and/or JCAHO standards
Previous experience in a Quality Management role in a health plan highly desired
Excellent listening, oral, and written communication/presentation skills
Ability to communicate complex information in a clear and concise manner
Strong problem solving, interpersonal, and customer service skills in both face-to-face and remote settings
Ability to work on multiple projects simultaneously and prioritize work to meet adapting deadlines
Ability to work in a collaborative fashion with various departments in data collection, clinical audits, and record maintenance
Ability to recognize potential and actual problems and work effectively within a team to develop appropriate solutions and implement effective action plans to address the problems
Demonstrated knowledge and experience in using critical thinking skills
Proficient with Microsoft Office Suite and Windows; experience with Access beneficial

Additional Information

All your information will be kept confidential according to EEO guidelines.

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