... NCQA. • 2+ years' experience in a UM team within managed care setting. • 3+ years' experience in clinical nurse setting preferred. • TPA Experience preferred. Powered by JazzHR nQSfGpNUXN
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... NCQA. • 2+ years' experience in a UM team within managed care setting. • 3+ years' experience in clinical nurse setting preferred. • TPA Experience preferred. Powered by JazzHR nQSfGpNUXN
Familiarity with state or federal digital health programs such as Client HIEA initiatives, Medicaid QPHE, or NCQA DAV. Desired 3+ years. * Experience working with rural or underserved provider ...
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Familiarity with state or federal digital health programs such as Client HIEA initiatives, Medicaid QPHE, or NCQA DAV. Desired 3+ years. * Experience working with rural or underserved provider ...
... NCQA DAV.Desired3YearsExperience working with rural or underserved provider settings.Desired3Years
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... NCQA DAV.Desired3YearsExperience working with rural or underserved provider settings.Desired3Years
Demonstrated expertise in health plan regulatory frameworks including CMS STAR ratings, HEDIS/NCQA standards, risk adjustment, and prior authorization regulations; ability to translate regulatory ...
Demonstrated expertise in health plan regulatory frameworks including CMS STAR ratings, HEDIS/NCQA standards, risk adjustment, and prior authorization regulations; ability to translate regulatory ...
Demonstrated expertise in health plan regulatory frameworks including CMS STAR ratings, HEDIS/NCQA standards, risk adjustment, and prior authorization regulations; ability to translate regulatory ...
Demonstrated expertise in health plan regulatory frameworks including CMS STAR ratings, HEDIS/NCQA standards, risk adjustment, and prior authorization regulations; ability to translate regulatory ...
Manager-Vendor Relations (Full-time Hybrid, Morrisville, North Carolina Based)
Morrisville, NC · Hybrid
Ensure contract is drafted in compliance with Alliance Health policies and procedures, Tailored Plan contract requirements, and NCQA standards. * Monitor vendor performance on the administrative ...
Manager-Vendor Relations (Full-time Hybrid, Morrisville, North Carolina Based)
Morrisville, NC · Hybrid
Ensure contract is drafted in compliance with Alliance Health policies and procedures, Tailored Plan contract requirements, and NCQA standards. * Monitor vendor performance on the administrative ...
Manager-Vendor Relations (Full-time Hybrid, Morrisville, North Carolina Based)
Morrisville, NC · On-site
Ensure contract is drafted in compliance with Alliance Health policies and procedures, Tailored Plan contract requirements, and NCQA standards. * Monitor vendor performance on the administrative ...
Manager-Vendor Relations (Full-time Hybrid, Morrisville, North Carolina Based)
Morrisville, NC · On-site
Ensure contract is drafted in compliance with Alliance Health policies and procedures, Tailored Plan contract requirements, and NCQA standards. * Monitor vendor performance on the administrative ...
Clinical Quality Management Analyst
Durham, NC · On-site
$73K - $117K/yr
DOI/ERISA/NCQA). Keeps abreast of medical knowledge, care patterns, regulatory and governmental rules and regulations. * Works with management team to support decisions on workflow process, quality ...
Clinical Quality Management Analyst
Durham, NC · On-site
$73K - $117K/yr
DOI/ERISA/NCQA). Keeps abreast of medical knowledge, care patterns, regulatory and governmental rules and regulations. * Works with management team to support decisions on workflow process, quality ...
Payer Healthcare Data Scientist, Manager
Raleigh, NC · On-site
$99K - $232K/yr
... NCQA HEDIS specifications and CMS Star Ratings - Knowledge of government payer programs and Medicaid - Experience with NLP or unstructured clinical text - Exposure to social determinants of health ...
Payer Healthcare Data Scientist, Manager
Raleigh, NC · On-site
$99K - $232K/yr
... NCQA HEDIS specifications and CMS Star Ratings - Knowledge of government payer programs and Medicaid - Experience with NLP or unstructured clinical text - Exposure to social determinants of health ...
Knowledge in interoperability and HL7 FHIR,FHIR work groupsand governing bodies(Da Vinci, Carin,Sequoia, NCQA, CMS, etc.). WhatYou'llGet * The opportunity to work at thecutting edgeof health care ...
Knowledge in interoperability and HL7 FHIR,FHIR work groupsand governing bodies(Da Vinci, Carin,Sequoia, NCQA, CMS, etc.). WhatYou'llGet * The opportunity to work at thecutting edgeof health care ...
Physician Reviewer-Radiology (Part Time)
Raleigh, NC · On-site
$95 - $100/hr
... NCQA) guidelines. * Aids and acts as a resource to Initial Clinical Reviewers. * Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and ...
Physician Reviewer-Radiology (Part Time)
Raleigh, NC · On-site
$95 - $100/hr
... NCQA) guidelines. * Aids and acts as a resource to Initial Clinical Reviewers. * Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and ...
Patient Service Representative
Lillington, NC · On-site
$14.75 - $18.75/hr
Assists in obtaining and maintaining NCQA PCMH recognition; * Faxing patient correspondence to outside entities from providers. This can include paper or electronic faxes depending on the type of fax ...
Patient Service Representative
Lillington, NC · On-site
$14.75 - $18.75/hr
Assists in obtaining and maintaining NCQA PCMH recognition; * Faxing patient correspondence to outside entities from providers. This can include paper or electronic faxes depending on the type of fax ...
Patient Service Representative
Lillington, NC · On-site
$14.75 - $18.75/hr
Assists in obtaining and maintaining NCQA PCMH recognition; * Faxing patient correspondence to outside entities from providers. This can include paper or electronic faxes depending on the type of fax ...
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Patient Service Representative
Lillington, NC · On-site
$14.75 - $18.75/hr
Assists in obtaining and maintaining NCQA PCMH recognition; * Faxing patient correspondence to outside entities from providers. This can include paper or electronic faxes depending on the type of fax ...
Field Medical Director, Vascular Surgeon
Raleigh, NC · On-site
$130 - $140/hr
... NCQA) guidelines. * Aids and acts as a resource to Initial Clinical Reviewers. * Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and ...
Field Medical Director, Vascular Surgeon
Raleigh, NC · On-site
$130 - $140/hr
... NCQA) guidelines. * Aids and acts as a resource to Initial Clinical Reviewers. * Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and ...
Endocrinology-Physician Reviewer-Radiology (Full-Time)
Raleigh, NC · On-site
$95 - $109/hr
... NCQA) guidelines. * Aids and acts as a resource to Initial Clinical Reviewers. * Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and ...
Endocrinology-Physician Reviewer-Radiology (Full-Time)
Raleigh, NC · On-site
$95 - $109/hr
... NCQA) guidelines. * Aids and acts as a resource to Initial Clinical Reviewers. * Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and ...
Ncqa information
What are the key skills and qualifications needed to thrive in the Ncqa position, and why are they important?
To thrive in an NCQA (National Committee for Quality Assurance) role, candidates typically need a strong background in healthcare quality assurance, data analysis, and knowledge of accreditation standards, often supported by a degree in healthcare administration or a related field. Familiarity with quality measurement tools, reporting systems like HEDIS, and NCQA accreditation processes or certifications is highly valued. Strong attention to detail, organizational skills, and the ability to communicate effectively with multidisciplinary teams set exceptional candidates apart. These skills are essential to ensure compliance, improve care quality, and navigate the complex requirements of healthcare accreditation.
How do you become NCQA certified?
To become NCQA certified, organizations must meet specific standards by submitting an application, undergoing a comprehensive review process, and demonstrating compliance through documentation and on-site assessments. The process often involves staff training, data collection, and continuous quality improvement efforts.
Is NCQA a good place to work?
NCQA offers roles related to healthcare quality measurement and accreditation, often requiring strong analytical skills and attention to detail. Employees report a professional environment with opportunities for growth, though experiences can vary based on position and department.
What does the NCQA do?
The NCQA (National Committee for Quality Assurance) is an organization that develops standards and measures to evaluate the quality of healthcare organizations and providers. Jobs related to NCQA often involve assessing compliance, data analysis, and quality improvement initiatives within healthcare settings.
What are some common responsibilities for professionals working in NCQA roles within healthcare organizations?
Professionals in NCQA roles are typically responsible for overseeing compliance with accreditation standards, conducting audits and quality assessments, and preparing documentation for NCQA reviews. They often collaborate with clinical and administrative staff to implement process improvements and ensure data accuracy in quality reporting systems such as HEDIS. Regular responsibilities may also include training teams on best practices, staying updated on changing quality standards, and leading initiatives to drive higher healthcare quality outcomes. This position offers meaningful opportunities to impact patient care and opens pathways to advanced roles in healthcare quality management.
What is an NCQA job?
An NCQA job typically involves working with healthcare organizations to ensure compliance with the National Committee for Quality Assurance (NCQA) standards. Professionals in these roles help organizations achieve accreditation or certification by implementing quality improvement processes, conducting audits, and analyzing data. Common NCQA-related positions include quality assurance specialists, accreditation consultants, and analysts who focus on managed care, population health, and performance measurement. These roles require knowledge of NCQA guidelines, healthcare regulations, and data analysis to support quality improvement initiatives.
How much does a NCQA VP make?
A Vice President (VP) at NCQA typically earns between $150,000 and $250,000 annually, depending on experience, location, and responsibilities. Compensation may also include bonuses and benefits, with senior roles requiring strong leadership and healthcare quality expertise.
What are popular job titles related to Ncqa jobs in Raleigh, NC? For Ncqa jobs in Raleigh, NC, the most frequently searched job titles are:
What job categories do people searching Ncqa jobs in Raleigh, NC look for? The top searched job categories for Ncqa jobs in Raleigh, NC are:
What cities near Raleigh, NC are hiring for Ncqa jobs? Cities near Raleigh, NC with the most Ncqa job openings:
Full-time
Posted 13 days ago
Job description
About The Role
BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.
Primary Responsibilities
• Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
• Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
• Collaborates with healthcare partners to ensure timely review of services and care.
• Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed.
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
• Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
• Triages and prioritizes cases and other assigned duties to meet required turnaround times.
• Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations.
• Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.
• Duties as assigned.
Essential Qualifications
• Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment.
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Must be able to work independently.
• Must be detail oriented and have strong organizational and time management skills.
• Adaptive to a high pace and changing environment- flexibility in assignment.
• Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
• Proficient in MCG and CMS criteria sets
• Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.
• Working knowledge of URAC and NCQA.
• 2+ years’ experience in a UM team within managed care setting.
• 3+ years’ experience in clinical nurse setting preferred.
• TPA Experience preferred.
BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.
Primary Responsibilities
• Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
• Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
• Collaborates with healthcare partners to ensure timely review of services and care.
• Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed.
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
• Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
• Triages and prioritizes cases and other assigned duties to meet required turnaround times.
• Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations.
• Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.
• Duties as assigned.
Essential Qualifications
• Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment.
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Must be able to work independently.
• Must be detail oriented and have strong organizational and time management skills.
• Adaptive to a high pace and changing environment- flexibility in assignment.
• Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
• Proficient in MCG and CMS criteria sets
• Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.
• Working knowledge of URAC and NCQA.
• 2+ years’ experience in a UM team within managed care setting.
• 3+ years’ experience in clinical nurse setting preferred.
• TPA Experience preferred.
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About Brighton Health Plan Solutions
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