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Emblem Health Quality & Training Analyst, UM Intake Ops in New York, New York

Partner with Medical Management Intake Operations Leadership to maintain an effective quality and training program to ensure operational and regulatory adherence with Federal, State and CMS regulations and NCQA accreditation requirements through monitoring and educational activities. Perform some training and mentoring functions to assist management.

Responsibilities:

Perform quality monitoring/audits, to measure adherence with state, federal, accreditation and business requirements associated with concurrent review utilization management requirements.

Perform components of mock audits, such as CMS, NCQA and State, on a routine basis with attention to the documentation.

Serve as participant in all external regulatory and accreditation audits.

Assist the Supervisor and Director in planning and executing against the established monitoring work plan; with coordination of the Medical Management Operations team for state, federal, accreditation and internal audits; and in annual review of the regulatory adherence grid, incorporating applicable Federal, State and accreditation decision-making and notification timeliness requirements..

Participate in the development of processes and procedures, desktop manuals and other reference tools.

Lead efforts to create effective training modules to ensure regulatory and accreditation adherence.

Assist/lead the new hire orientation and training, annual training and ad hoc training for end to end processes.

Provide coaching to staff on individual results, sharing feedback and expected improvements to direct leaders

Develop effective corrective action plans with departmental leadership.

Track completions of other trainings and required evaluations annually, including mandatory trainings and evaluation of intake team.

Provide quality results, documenting issues and ensures appropriate corrective actions plans are deployed, including effectiveness therein.

Maintain a working knowledge of relevant issues, laws, and regulations affecting Medical Management Operations.

Perform other tasks as assigned.

Qualifications:

Bachelors degree

3 years experience in a managed healthcare environment.

Additional years of related experience may be considered in lieu of educational requirements

2 years of previous quality/audit and training experience.

Prior experience with CMS regulations and NCQA accreditation.

Strong communication and presentation skills and the ability to interact with all levels of management and state, federal regulatory and accreditation agencies.

Excellent analytical, organizational, and problem-solving skills.
Ability to multi-task many projects simultaneously.

Additional Information

  • Requisition ID: 200XE


Equal Opportunity Employer-minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity

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