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The Health Plan Accreditation and Clinical Excellence Lead is primarily responsible for the maintenance of accreditation, management of the process for attaining accreditation and supporting initiatives to promote adherence with accreditation, regulatory and contract requirements.
Key Responsibilities: Interface with internal and external clients, quality committees, and departments in the review of quality improvement data, clinical trends and in the implementation of appropriate interventions to effect improvement.
Develop, review, implement and oversee the effective administration of policies and procedures, in partnership with key stakeholders, to facilitate accreditation, regulatory and contract compliance.
Act on priority objectives to achieve desired results using knowledge of business drivers, operations, and capabilities to influence strategies to drive clinical excellence and adherence with accreditation, regulatory and contract requirements.
Act as primary client liaison in responding to client requests for documentation needed for delegation oversight audits and/or to demonstrate evidence compliance with accreditation, regulatory or contract requirements.
Provide mentoring to leads to drive clinical excellence and strengthen Utilization Management and Quality Management program effectiveness.
Identify, research, process, resolve and respond to customer clinical complaints, in collaboration with the Medical Director, Medical Management Director and Clinical Leads.
Analyze and aggregate data to demonstrate compliance with policies, contract, regulatory and accreditation requirements.
Evaluate, interpret and summarize quantitative and qualitative data for presentation to the Quality Committee, and oversee quality improvement activities.
Consult and coordinate with internal departments on potential or identified quality issues and assist in development and implementation of action plans as needed.
In collaboration with the Medical Director and Medical Management Director, coordinate Quality Committee activities and meeting agenda.
Perform periodic and on demand compliance reviews and audits to identify opportunities and monitor compliance.
Facilitate training for clinical and non-clinical staff on Accreditation and Regulatory requirements, Quality Management topics, audit methodologies and related improvement initiatives.
Develop and support the development of training material as needed to address opportunities and reinforce best practices to drive operational and clinical excellence.
Serve as a clinical subject matter expert resource for UM, Training and Quality staff.
Manage the process for accreditation activities, including reaccreditation, accreditation of new sites, implementing new policies or revising existing policies to reflect changes in accreditation standards or changes in interpretation of standards, coordinating accrediting agency audits, responding to questions of accrediting agencies , and making filings to accrediting agencies.
Compile evidence and documentation that accreditation standards and/or regulatory requirements have been met.
Conduct the ongoing evaluation and interpretation of quality standards and accreditation standards to ensure compliance through reporting and measurement studies/ methodologies .
Work with Compliance Manager to implement policies and to implement policy changes needed to maintain compliance with accreditation standards.
Develop comprehensive accreditation and clinical excellence initiative work plans by establishing deliverables , accountabilities, and timelines.
Coordinate activities for successful accreditation surveys.
Provides accreditation subject matter expertise to enterprise business owners.
Writes content for newsletters and forums to promote accreditation, regulatory, contract requirement compliance and clinical excellence.
Performs other job-related duties as assigned.
Additional tasks may be assigned by your Immediate Supervisor/Project Manager Job Requirement: No travel at this time.
Potential for International and Domestic in the future.
Some hours outside typical 9-5 and On-Call as needed Basic Qualifications Minimum of 3 years’ experience in a managed care organization working in quality improvement and/or utilization management Minimum of 3 years’ experience in a clinical setting Minimum of 3 years’ experience with NCQA (National Committee for Quality Assurance) and URAC (Utilization Review Accreditation Commission) accreditation Preferred Skills/Experience BA/BS in a health care field; BSN preferred Registered Nurse Licensure in any US state or territory preferred Previous clinical training experience Outlook, Microsoft Word, Excel, PowerPoint at least basic proficiency Proven ability to work collaboratively with diverse individuals and situations Excellent client and customer service skills, and excellent written and verbal communication skills required.
Demonstrated teamwork and collaboration in a professional setting; either military or civilian Project management experience Knowledge of evidence based guidelines and tools such as InterQual, Milliman, CMS guidelines Strong written and verbal communication skills Strong quantitative, qualitative and analytical skills or any combination of education and experience, which would provide an equivalent background As required by Colorado law under the Equal Pay for Equal Work Act, Accenture provides a reasonable range of minimum compensation for roles that may be hired in Colorado.
Actual compensation is influenced by a wide array of factors including but not limited to skill set, level of experience, and specific office location.
For the state of Colorado only, the range of starting pay for this role is 110,400 to 235,200 and information on benefits offered is here.
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Requesting An Accommodation Accenture is committed to providing equal employment opportunities for persons with disabilities or religious observances, including reasonable accommodation when needed.
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