• Clinical Appeals Nurse

    Centene Corporation (Columbia, SC)
    …ensuring that all appeal letters generated comply with both State and NCQA requirements. + Review clinical information for all appeals utilizing nationally ... appeals and ensure letters are compliant with State and NCQA standards. + Maintain files and logs for all...determinations or clinical rationale + Maintain current knowledge of NCQA and State regulations + Coordinate Fair Hearings with… more
    Centene Corporation (08/03/25)
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  • Program Director, Quality Improvement (Remote)

    Molina Healthcare (Vancouver, WA)
    …measurement activities; and provides direction and implementation of NCQA accreditation surveys and federal/state QI compliance activities. ... provides the strategic direction and implementation of corporate and/or Molina plan NCQA accreditation surveys and federal and state QI Compliance activities. +… more
    Molina Healthcare (08/02/25)
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  • Member Appeals and Grievance Intake Admin…

    Fallon Health (Worcester, MA)
    …process is an essential function to FH's compliance with CMS regulations, NCQA standards, other applicable regulatory requirements and member expectations. The FH ... Handbook/Evidence of Coverage for all products, and in compliance with applicable NCQA standards and other state or federal regulatory requirements. Strict adherence… more
    Fallon Health (08/01/25)
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  • Health Plan Pharmacy Services Manager (SC…

    Molina Healthcare (Kenosha, WI)
    …for review. + Assures that activities and processes are compliant with NCQA guidelines and Molina policies and procedures and promotes best practice measures ... Quality Management and Health Education programs including, but not limited to, NCQA Accreditation, HEDIS, and Disease Management programs company wide. + Attends… more
    Molina Healthcare (07/24/25)
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  • Manager I, Pharmacy Operations

    Blue Cross Blue Shield of Massachusetts (Hingham, MA)
    …to assess team and individual metrics and in compliance with required reporting for NCQA , CMS and other stakeholders as needed. + Evaluate, plan and mange staffing ... to maintain all regulatory requirements including, but not limited to, NCQA , MCRA, CMS for turnaround times, documentation, notifications and audit activities.… more
    Blue Cross Blue Shield of Massachusetts (07/23/25)
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  • Senior Clinical Review Nurse - Correspondence

    Centene Corporation (Phoenix, AZ)
    …Reviews outcomes in accordance with National Committee for Quality Assurance ( NCQA ) standards. Works with senior management to identify and implement opportunities ... on denial determinations in accordance with National Committee for Quality Assurance ( NCQA ) standards + Audits and revises correspondence letters to ensure they are… more
    Centene Corporation (07/19/25)
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  • Senior Medical Director - Sharp Health Plan…

    Sharp HealthCare (San Diego, CA)
    …collaboration necessary for the continuum of care foundation for our NCQA required population health management program. Additionally, this position provides the ... clinical teams. + Assists CMO in the implementation of NCQA top decile improvement programs and work plans. +...committees, and the SHP Chief Medical Officer. + Supports NCQA survey activities. Prepares for site visits and responds… more
    Sharp HealthCare (07/19/25)
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  • Clinical Quality Director - Stars/HEDIS

    Elevance Health (Atlanta, GA)
    …of health care management to direct the clinical quality initiatives, including NCQA accreditation and compliance with regulatory agencies and other objectives. The ... training and continuing education of staff regarding standards and guidelines, including NCQA and HEDIS. + Hires, trains, coaches, counsels, and evaluates the… more
    Elevance Health (07/18/25)
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  • Lead Abstractor, HEDIS/Quality Improvement (Remote…

    Molina Healthcare (Idaho Falls, ID)
    …+ Assists as needed in support of accreditation activities such as NCQA reviews, CAHPS and state audits by reviewing clinical documentation. + Provides ... review and abstraction + Intermediate knowledge of HEDIS and NCQA **PR** **E** **FE** **R** **RED E** **X** **PE**...managed care experience. + Advanced knowledge of HEDIS and NCQA . **PR** **E** **FE** **R** **RED L** **I** **C**… more
    Molina Healthcare (07/17/25)
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  • Quality Management Clinician

    UPMC (Media, PA)
    …performing functions related to quality management and improvement in compliance with NCQA , HEDIS, URAC, and the Commonwealth of Pennsylvania Department of Health ... and grievance for further action. + Responsible for assisting with preparation for NCQA , URAC, and other site visits. + Responsible for participating in updating the… more
    UPMC (07/17/25)
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