Delegation Oversight Coordinator - JHP

Job Details

This position is responsible to interface with delegated provider groups, overseeing the credentialing and re-credentialing activities and complete required auditing and reporting related to provider/subcontractor delegation, and ensure adherence with the NCQA, State and Lines of business requirements. Conduct provider delegation audits on an ongoing basis.

Job Description

Essential Functions:

• Enters and supervises the data that is received on all incoming delegated profiles.
• Communicate with internal departments regarding the delegation process as necessary.
• Review delegated profiles for completion and request missing information.
• Review various sources for sanctions.
• Ensure timeliness and accuracy of the credentialing and recredentialing processes.
• Maintain practitioner files for designated area.
• Assure quality network of practitioners through consistent application of the Health Partners’ Credentialing and Recredentialing Policy requirements.
• Perform all data entry into Credentialing Database for practitioners credentialed, re-credentialed and for any PDC changes received.
• Schedule all delegated oversight audits timely and send confirmation of the audit dates.
• Accurately perform all delegated oversight audits. This includes all local and non-local audits.
• Accurately complete the delegated oversight audit scores after each audit and submit them to the Credentialing Committee Meetings.
• Ensure each delegated entity receives their audit scores timely after each Credentialing Committee Meeting.
• Ensure the timely receipt of all quarterly reports for presentation to the Credentialing Committee for review and approval.
• Perform other duties as assigned.

Work Environment:
The job operates in a healthcare office setting.

Physical Demands:
While performing the duties of this job, the employee is regularly required to talk and hear. The position mainly sitting environment but may at times require standing, walking, bending, kneeling and stooping all day. The employee may have to lift and/or move items over 20 pounds.

Required Education and Experience:
High school diploma required.
Associate degree preferred.
Minimum 1 year managed care or healthcare experience preferred.
CPCS Certification preferred.

Skills/Abilities:
Demonstrate maturity and professionalism, strong communication, problem-solving, and
team building skills preferred.
Required knowledge of Microsoft Office (Excel and Outlook).
Excellent attention to detail and organizational skills, knowledge of NCQA, DHS, CMS, and DOH preferred.
Ability to work independently and as part of a team preferred.

Access to Protected Health Information:
Position will have access to Protected Health Information. Chosen candidate is required to adhere to Health Partners’ policies and procedures, including those regarding HIPAA and Protected Health Information.

Medicare Advantage Compliance Statement:
Compliance with all applicable rules, regulations and laws is a condition of employment. Employees must read and sign, both the Business Code of Conduct and the Personal Standard Code of Conduct, and are expected to perform their duties ethically and honestly.

Other Duties:
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for their job. Duties, responsibilities, and activities may change at any time with or without notice.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University , home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200 undergraduate and graduate programs to more than 8,300 students. Jefferson Health , nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps ), have access to medical (including prescription) insurance.

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