Remote Nicu Utilization Review Jobs in Raleigh, NC

The NCQA Quality & Accreditation Specialist serves as the project management lead and subject matter expert for assigned NCQA standard areas and manages the assessment of related business functions for corresponding departments within the scope of NCQA standards (e.g. Provider and Member Services, Utilization Management, Population Health, Care Management, Provider Network, Member and Provider Communications, Delegation Oversight) to support high-quality performance and ensure successful NCQA Accreditation process.

This position is fulltime remote. While there is no expectation of being in the office routinely, they may be required to report to the Alliance Home Office (Morrisville, North Carolina) for business meetings as needed.

Responsibilities & Duties

Implement and Monitor Accreditation Workplan

• Project management lead for assigned NCQA standard categories within the organization’s QI workplan to achieve and maintain Health Plan Accreditation with LTSS distinction and any additional accreditations Alliance Health pursues
• Identify gaps and risks and provide regular status reports from NCQA tracker to leadership
• Serve as lead for NCQA Accreditation reviews for assigned standard categories by gathering all necessary documents and information from business areas, managing timely document submissions to NCQA, facilitating NCQA requests for additional information, and coordinating onsite review activities
• Review and update policies and procedures, reports, materials, and files for completeness, accuracy, and compliance with NCQA Standards
• Maintain calendar of documentation due dates, ongoing collection and tagging relevant policies/procedures, reports, materials, and files as appropriate
• Participate in Delegation Oversight and audits as appropriate

Drive Organizational Accreditation Efforts

• Provide technical support and education to staff regarding NCQA Health Plan Accreditation and LTSS Distinction Standards and supporting documentation
• Assess business area functions against current and upcoming NCQA standards and identify potential performance gaps and associated risks and update NCQA tracker upon release of new/updated standards
• Serve as the accreditation subject matter expert within organizational wide, cross-functional, and multi-disciplinary teams to bring each business area to a state of readiness
• Identify and facilitate business area process improvements via means such as policies, workflows, and processes; follow-up to ensure improved outcomes
• Coordinate and collaborate with cross-departmental teams to identify and implement organization-wide strategic initiatives that support quality performance
• Communicate reporting due dates and reminders to business leads and leadership as appropriate
• Maintain clear status updates regarding NCQA Readiness on NCQA Tracker, communicating risks as appropriate

Minimum Requirements

Education & Experience

Required:

Bachelor’s degree in Healthcare, Human Services, Public Health Administration, Nursing, Business, or related field and three (3) years of project management experience in a managed care or healthcare setting with knowledge and practical experience health care quality or NCQA Health Plan accreditation processes and requirements.

Preferred:

Experience with NCQA Accreditation standards. 

Knowledge of regulatory reporting, compliance requirements, and auditing procedures. 

Project management.

Knowledge, Skills, & Abilities

• Knowledge of NCQA accreditation processes and standards
• Knowledge and understanding of federal and state regulations
• Planning, project management and organizational skills
• Excellent communication skills (written and verbal). 
• Interpersonal skills which are effective, respectful, and sensitive to a diverse and multicultural population of children, families, and co-workers, 
• Problem-solving, mediation, and conflict resolution skills
• Teamwork and collaboration skills
• Microsoft Project, Excel, Word (Edits and Tracking), and PowerPoint skills 
• Facilitation skills
• Ability to work in a fast-paced environment with frequent interruptions
• Ability to work under minimal supervision

 Salary Range 

$69,592 - $88,729/ Annual 

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity 

 An excellent fringe benefit package accompanies the salary, which includes:   

• • Medical, Dental, Vision, Life, Long Term Disability
  • Generous retirement savings plan
  • Flexible work schedules including hybrid/remote options
  • Paid time off including vacation, sick leave, holiday, management leave
  • Dress flexibility