Quality & Compliance Coordinator

Job Description

Job Description

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing Whole-Person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 4,000 providers including Primary Care, Specialty, Hospital System and ancillary provider partnerships. We have operated in the Arizona market for more than 15 years, and are based in Chandler, Arizona. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.

The QI & Compliance Coordinator is responsible for providing support with administrative and operational functions within the Quality and Compliance departments. Specifically, this includes: receiving/processing/tracking member Appeals/Grievances, Provider Surveys, as well as assisting the Compliance department with activities such as training, auditing, reporting, investigating, scheduling, and administrative assistance for Fraud, Waste, Abuse and Privacy issues. This position will report directly to the Credentialing & Prior Auth Director, however, will also support the Regional Compliance Officer with the planning of compliance and safety committee meetings in Arizona.

Other responsibilities may include: monitoring of the annual compliance training for contracted providers, updating the training modules as directed by HPN, and serving as a liaison for any health plans, related to compliance and quality.

The QI & Compliance Coordinator provides strong support to the department, which requires exceptional customer service and technical skills (various spreadsheets, tables, graphs, audit tools, electronic file maintenance, etc.) and familiarity with various computer programs and office equipment, excellent written and verbal communication skills and professionalism.

POSITION DUTIES & RESPONSIBILITES

Quality

• Ensures proper processing of initial receipt, entry and investigation of Appeal/Grievance cases, including appropriate medical record requests and professional inquiries.
• Ensures professional response letters to health plans, summarizing AZPC findings and actions.
• Ensure maintenance of accurate databases for statistics reporting, case tracking and health plan turnaround compliance.
• Participates with PCP/staff education, regarding Appeals & Grievances and request CAP.
• Assists management with quarterly Quality Improvement Committee (QIC) meeting preparation, to include creation of agenda, meeting invites, takes meeting minutes, and presentations.
• Finalizes all post committee documents with management's signatures on QIC documents. Finalizes policies and programs and notifies Department heads.
• Assists in preparation of audit files for the NCQA certification and Health Plan audits.
• Completes spreadsheets and audit tools for various Quality activities, as well as necessary revisions to tools.
• Helps create various reports, audit tools, and training materials.
• Collaborates with management on the creation of new QI SOPs and annual review, thereafter, ensuring notification of new or updated P&P's are presented at appropriate UM/QI Committee.
• Assists with conducting member satisfaction surveys, data entry of results and submission of initial summary of findings to Director.
• Assists with collecting medical records and other pertinent documentation.
• Ensures scanning has been completed for Appeal/Grievances and other QI case files into electronic storage system.

Compliance

• Assists with preparations, administration and conducting of Compliance/Safety Committee meetings.
• Assist with conducting compliance audits of our contracted providers – First Tier, Downstream and Related Entities (FDR's).
• In conjunction with Provider Relations, collect annual compliance training attestations from all FDR's.
• Under the direction of Compliance Officer, perform departmental or walk-through site audits/surveys for Compliance/Privacy/Security/Safety, and perform Risk Assessments and special investigations.
• Under the direction of Compliance Officer, perform employee telecommuting inspections or walk-though audits/surveys for Compliance/Privacy/Security/Safety.
• Review reports from Health Plans, internal reports and data, or other sources to assist in identifying deficiencies or new regulatory requirements.
• Support departmental or centralized health plan audit or monitoring across assigned groups.
• Assist Compliance Officer & Privacy Officer with developing risk analyses, auditing work plan, and reviews auditing and monitoring reports; identifies potential areas of compliance vulnerability and risk and develops and implements corrective action plans for resolution of issues, monitoring effectiveness of change.
• Assists with completion of spreadsheets and audit tools for various Compliance activities, as well as necessary revisions to tools.
• Assist with various reports, audit tools, presentations and training materials.

EDUCATION, TRAINING AND EXPERIENCE

• Highschool diploma or equivalent required (GED). Associates degree in related field desired.
• Prior experience in the medical field, with proficient knowledge of medical terminology and data entry; physician front office experience preferred.
• Exceptional computer skills and experience using Microsoft Word, Excel, Power Point.
• Must possess excellent communication skills, with an ability to interact effectively with internal and external customers in a pleasant and professional manner.
• Exceptional organizational and project management skills with strong attention to detail and accuracy, and ability to reprioritize tasks when requested.
• Exceptional interpersonal, verbal and written communication skills, including proofreading and grammar skills.
• Must be able to meet project deadlines.
• Ability to work independently with minimum supervision.
• Driving occasionally required, current and unrestricted AZ driver license with proof of insurance required.

This role requires 60 days FT in office presence, hybrid options will be available after the 60-day period.