Job Summary
The Provider Services Auditor is responsible for the timely and accurate maintenance and reporting of Atrium 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. This position is also responsible for management and oversight of operational quality review programs for the Managed Care Credentialing Department, supporting all activities required to credential Atrium Health providers with contracted managed care payers. These activities include but are not limited to ongoing QA review of staff work, auditing of provider files, support of external audits as required by contracted payers and regulatory entities and reporting of quality metrics to management. Manages and oversees the comprehensive quality assurance and training programs.
Essential Functions
- Regularly audits the credentialing databases and activity audit trails for adherence to established departmental processing policies and procedures.
- 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.
- Creates and produces effective management reporting, analyzing, and identifying key issues and trends in provider data management and communicating to MHR leadership as needed.
- Creates and maintains quality sampling, review, and reporting policies and procedures that are effective and objectively compliant. Provides necessary definition, development and deployment of quality assurance strategy to address all phases of quality management.
- Collaborates with senior specialists on teammates quality reviews, training, preparation and content of staff performance evaluations and development of action plans related to identified staff performance deficiencies.
- Solicits input and works interactively with stakeholders in other areas to ensure effective cross-functional cooperation on shared quality and training objectives.
- Creates and maintains effective training materials, policies, and procedures. Provides necessary definition, development, and deployment of training plans and strategy addressing all phases of training.
- Confers with management and conducts surveys to identify educational needs based on projected growth, changes in processes, and payer requirements.
- Develops and deploys e-learning and self-paced training capabilities.
- Supports leadership as quality and education subject matter expert for audits of credentialing files requested by delegated managed care organizations and outside regulatory agencies.
- Maintains records of audit results, action plans, and managed care contacts.
- Establishes and maintains a policy for documentation of all quality and education processes and guidelines and ensures departmental documentation is maintained in compliance with external regulatory standards.
- Serves as a subject matter resource for managed care credentialing, government enrollment, and provider data management to MHR and to the Provider Services teams.
- Serves as a Team lead for the units when the regular Team Leads are out of the office.
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.
Atrium Health is one of the nation’s leading healthcare organizations, connecting patients with on-demand care, world-class specialists and the region’s largest primary care network. A recognized leader in healthcare delivery, quality and innovation, our foundation rests on providing clinically excellent and compassionate care.
We’ve been serving our community since 1940, when we opened our doors as Charlotte Memorial Hospital. Since then, our network has grown to include more than 40 hospitals and 900 care locations ranging from doctors’ offices to behavioral health centers to nursing homes.
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