Position Purpose: Oversee all related activities for the Quality Improvement and Credentialing functions. Lead and direct process improvement activities for more efficient and streamlined workflow.
- Responsible for all activities related to National Committee for Quality Assurance (NCQA) Accreditation and/or Healthcare Effectiveness Data and Information Set (HEDIS) performance
- Ensure health plan is compliant and become or remain accredited with NCQA
- Responsible for credentialing and re-credentialing of providers, including all physicians and mid-level practitioners, in accordance with Plan specifications and credentialing committee
- Manage the credentialing process for all non-delegated practitioners and providers.
- Review and implement new technological tools and processes and foster team concept with internal and external constituencies
- Present results of improvement efforts and ongoing performance measures and recommend actions plans to senior management
- Research and incorporate best practices into operations
- Organize and control activities, methods, and procedures to achieve business objectives
- Formulate and establish policies, operating procedures, and goals in compliance with internal and external guidelines
Knowledge/Experience: Bachelor's degree in Nursing or related clinical field. 10 years of healthcare operations experience, including quality improvement experience. Masters’ degree preferred.
License/Certificates: Current state’s RN license. Certified Professional in Health Care Quality preferred.