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Provider Services Auditor - Atrium Health/REMOTE

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Charlotte, NC, United States
Job ID: 28316
Job Family: Professional Services
Status: Full Time
Shift: Day
Shift Details: Regular
Department Name: 51011028341158-Provider Credentialing
Location: Atrium Corporate Operations

Overview

Job Summary

Responsible for the timely and accurate maintenance and reporting of CHS provider group and individual provider data, as well as CMHA practice data. These activities include but are not limited to conducting regular managed care directory audits, data loading, maintenance, and extraction; query, analysis, editing, and reconciling provider data; and reporting to managed care payers and other external entities, and internally to management.

Essential Functions

Quality Management

• Creates and maintains, independent of line management, effective quality sampling, review, and reporting policies and procedures that ensure compliance     with external entities (i.e. NCQA) and managed care payer guidelines. Provides necessary definition,   

  development and deployment of quality assurance strategies to address all phases of quality management.

• Performs regular audits of managed care credentialing files for compliance with departmental processing guidelines and policies, as well as external regulatory requirements.

• Regularly audits the credentialing databases and activity audit trails for adherence to established departmental processing policies and procedures. Reviews, analyzes, and reports on the validity, accuracy, and completeness of the data

• Works with interdepartmental teams, implements processes, and develops quality assurance metrics for continuous performance improvement.

• Creates and produces effective quality management reporting, analyzing and communicating data on quality metrics and key performance indicators to senior MHR leadership monthly or as needed.

• Solicits input and works interactively with stakeholders in other CHS areas to ensure effective cross-functional cooperation on shared quality objectives.

• Supports Director as subject matter expert for managed care credentialing, managed care payer, and government enrollment reporting, as well as database functions and systems data integrity.

 

Managed Care Payer Reporting

• Prepares and reviews monthly and quarterly provider network reports sent to contracted managed care payers for adherence to departmental policies and procedures, as well as managed care payer requirements.

• Audits and confirms accurate and timely loading of providers by managed care payers, and follows up on specific issues related to loading providers as needed.

• Collaborates with Directors and contracted managed care payers to continually improve and enhance managed care reporting tools.

• Routinely communicates with MHR Contracting & Payer Relations Directors and staff regarding contract changes with contracted managed care payers, as well as practice level CMHA changes.

• Collects and distributes monthly roster of applicable CMHA practices linked to MHR/CHS agreements to applicable managed care payers.

• Prepares activity and progress reports related to these efforts, and supports internal and external quality reviews which require provider data extracts.

 

Provider Data Management

• Develops and implements effective provider data management, review, and reporting policies/procedures to ensure the ongoing integrity of provider data and compliance with reporting requirements of managed care payer and other external regulatory entities

 (i.e., DOI) and oversight bodies (i.e., NCQA).

• Regularly audits MOAD, ECHO, and other provider databases; reviews, analyzes, and reports on the validity, accuracy, and completeness of the data.

• Creates and produces effective management reporting, analyzing, and identifying key issues and trends in provider data management and communicating to MHR leadership as needed.

 

Physical Requirements

Performs most work under normal office conditions. May include sitting for long periods of time, standing, walking, using repetitive wrist and arm motion or lifting articles up to twenty-five pounds.

Education, Experience, and Certifications

Bachelor’s degree in a related field is required. BA/BS in business or other analytical area preferred. 1-3 years prior experience in an operational quality management role in a managed care plan, insurer, or a related processing or compliance setting required. Prior managed care credentialing experience and working knowledge of managed care payer, Medicare, Medicaid, NCQA, and data standards preferred. Prior experience leading and managing a team is preferred. Strong Proficiency with Microsoft Excel and other applications, data integrity principles, and developing and creating reports in varied formats is required. Understanding of managed care credentialing and government enrollment processes, policies, and guidelines is required. Strong listening, written /verbal communication, and presentation skills, and superior interpersonal and teaming skills are required. Experience in conducting statistically valid quality reviews, analyses, and audits, developing and executing performance improvement action plans, and attaining organizational goals is required. Experience in word processing and business correspondence is required. High degree of organizational skills and problem-solving skills is required.