- Evolent (Lansing, MI)
- …Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ( 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 accurate manner. + Participates in on-going training per inter-rater reliability process. + May assist the Senior Medical Director… more
- AmeriHealth Caritas (Detroit, MI)
- …programs, and applicable regulatory, state, and National Committee for Quality Assurance ( NCQA ) requirements. + May identify cases to be presented at care management ... rounds and follow up with providers on recommendations to achieve optimal outcomes for members. + For education and/or assessment, face-to-face visits may be required at the member's residence, provider's office, hospitals, other acute locations, or community… more
- CVS Health (Lansing, MI)
- …**Compliance & Quality** + Ensure digital products adhere to HIPAA, CMS, NCQA , and other relevant healthcare insurance regulations. + Partner with compliance and ... security teams to maintain data integrity, privacy, and security standards. **Performance Tracking** + Define KPIs and success metrics to measure adoption, satisfaction, and ROI. + Continuously monitor and optimize products post-launch to maximize value… more
- Integra Partners (Troy, MI)
- …compliance with all regulatory, contractual, and accreditation standards (CMS, NCQA , state-specific requirements). + Support audit preparation, quality initiatives, ... and corrective action plans as needed. + Oversee case assignment, queue management, and authorization workflows to ensure timely completion. + Perform authorization reviews as needed, utilizing federal/state mandates, plan benefit language, and medical… more
- Evolent (Lansing, MI)
- …Experience with value-based care, utilization management, or regulatory reporting (eg, HEDIS, NCQA , Milliman). **To comply with HIPAA security standards (45 CFR sec. ... 164.308 (a) (3)), identity verification may be required as part of the application process. This is collected for compliance and security purposes and only reviewed if an applicant advances to the final interview state. Reasonable accommodations are available… more
- Molina Healthcare (MI)
- …role. + 3+ years managed care experience. + Advanced knowledge of HEDIS and NCQA . **PR** **E** **FE** **R** **RED L** **I** **C** **E** **N** **S** **E,** **C** ... **E** **R** **TI** **FI** **C** **A** **T** **I** **O** **N** **, AS** **S** **O** **C** **I** **A** **TI** **O** **N** **:** Active RN license for the State(s) of employment **PHY** **S** **I** **C** **AL DEM** **A** **N** **D** **S** **:** Working… more
- Evolent (Lansing, MI)
- …Review Accreditation Commission (URAC) and National Committee for Quality Assurance ( NCQA ) guidelines. + Provides clinical rationale for standard and expedited ... appeals. + Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner. + Participates in on-going training per inter-rater reliability process. + On a requested basis, may function as… more
- Trinity Health (Grand Rapids, MI)
- …and company policies and procedures. + Maintains standard workflow to meet NCQA standards alignment and manages patient caseload to meet annual contract patient ... care goals. **Our Commitment** Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow… more
- Evolent (Lansing, MI)
- …providing optimum customer service through professional/accurate communication and maintaining NCQA and health plans required timeframes. + Documents all ... communication with medical office staff and/or treating provider. + Practices and maintains the principles of utilization management by adhering to policies and procedures. + Participates in on-going training programs to ensure quality performance in… more
- Evolent (Lansing, MI)
- …Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance ( 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 accurate manner. . May assist the Senior Medical Director in research activities/questions related to the Utilization Management… more