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- ...service. Depending on the nature of the case, telephonic peer to peer discussions may be required. The incumbent ensures compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times. In addition to utilization review, the incumbent participates as the physician...SuggestedTemporary workPrivate practiceRemote work
- ...Microsoft Office Applications; Excel, Outlook, Word, and Teams ~2 years’ experience with CAQH requirements and review ~2 years NCQA standards related to credentialing. ~ The ability to create spreadsheets, analyze data and identify trends. ~ Strong attention to...SuggestedRemote jobWork at officeWork from home
- ...engagement platforms, dialers, or telephony configuration Knowledge of payer-specific compliance and regulatory frameworks ( CMS, NCQA, HIPAA, data governance in regulated environments) Track record of scaling implementation processes across multiple customers or...SuggestedFull timeContract work
Hippocratic AI
Remote15 days ago - ...licenses, board certifications, malpractice insurance, and work history with complete accuracy. Ensure all credentialing files meet NCQA, TJC, CMS, and payer-specific requirements. Payer Enrollment and Maintenance Prepare, submit, and track enrollment...SuggestedRemote jobFull timeWork at office
- ...Review and distribute all incoming mail as needed Support Payer Audits in accordance with Minute Clinic, Joint Commission and NCQA requirements Maintain provider files with the most current information/documentation Notify system analyst and leadership of any...SuggestedRemote jobWork at office
$78k - $85k
...Spanish. Obtain and utilize clinical information to develop an individualized member care plan and clinician-centered care plan per NCQA guidelines. Assess members health status and care coordination needs. Collaborate with members' health care providers as...SuggestedRemote jobFull timeNight shiftDay shiftAfternoon shift$250k - $290k
...outcomes, and you’d rather measure than guess. Active medical license in good standing in one or more states. Able to pass NCQA credentialing and Wheel’s standardized background checks. Nice to have Don’t let these stand in your way—they’re just...SuggestedRemote jobFull timeTemporary workWork experience placementFlexible hours- ...collaboration. Assist with reporting, metrics tracking, and monitoring of key performance indicators (KPIs). Promote compliance with NCQA , CMS , state and federal regulations, health plan requirements, and organizational policies. Maintain strict adherence to...SuggestedFull timeWork at officeRemote work
NeueHealth
Remotea month ago - ...and reimbursement. Maintain compliance with all payor requirements, accreditation standards, and regulatory mandates (e.g., CMS, NCQA, CAQH). Revenue Cycle Operations: Oversee the full revenue cycle including patient access, billing, coding, A/R, charge...SuggestedContract workRemote work
- ...Preferred Qualifications: ~ Direct experience or familiarity with the accreditation process (e.g., The Joint Commission, CARF, NCQA, or other), specifically within Behavioral Health Care and Human Services (BHC) or virtual/telehealth models Compensation...SuggestedRemote jobFull timeContract workFor contractors
- ...care or health plan experience in credentialing compliance,auditing, and quality assurance Skills: ~2 years’ experience with NCQA compliance ~01-year MDStaff experience/ preferred ~03+ years of related health care or health plan experience in credentialing compliance...SuggestedRemote jobWork at office
- ...insurance authorization processes, medical billing, and coding (e.g., ICD-10, CPT codes ). Working knowledge of MCG, InterQual, and NCQA standards . • Skills: Strong analytical and critical thinking skills to assess medical necessity. Proficient in medical...SuggestedFull timeWork at office
NeueHealth
Remote12 days ago - ...authorization processes, medical billing, and coding (e.g., ICD-10 , CPT codes ). Working knowledge of MCG , InterQual , and NCQA standards . Skills: Strong analytical and critical thinking skills to assess medical necessity. Proficient in medical...SuggestedFull timeContract workWork at office
NeueHealth
Remote12 days ago - ...mental health care Preferred Qualifications: ~ Direct experience or familiarity with the accreditation process (e.g., The Joint Commission, CARF, NCQA, or other), specifically within Behavioral Health Care and Human Services (BHC) or virtual/telehealth models...SuggestedContract workFor contractors
Lyra Health
Remote14 days ago $78.4k - $107.8k
...standards across multiple operational areas within Humana. Serve as subject matter expert on National Committee for Quality Assurance (NCQA) Health Plan Accreditation and Long-Term Services and Supports (LTSS) requirements, advising stakeholders on compliance, and...SuggestedFull timeTemporary workApprenticeshipWork at officeRemote workWork from homeHome officeMonday to Friday$31.2k - $33.28k
...services requested require precertification based on the employer’s/Third Party Administrator’s contract with MedWatch based on NCQA, URAC and state standards. This is a remote position with no requirement to commute to an office. Education: ~ High School...Hourly payFull timeContract workRemote workHome office- ...collaboration. Assist with reporting, metrics tracking, and monitoring of key performance indicators (KPIs). Promote compliance with NCQA , CMS , state and federal regulations, health plan requirements, and organizational policies. Maintain strict adherence to...Full timeWork at officeRemote work
NeueHealth
Remotea month ago $45.76k - $52k
...issues or rejections with payers. Compliance & Maintenance Ensure all credentialing and enrollment activities are compliant with NCQA, CMS, and payer-specific guidelines. Monitor and update records for expiring licenses, DEA certifications, malpractice insurance,...Full timeWork at officeRemote work$115k - $149k
...with US reimbursement structures (CMS, Medicare Advantage, commercial payers) and their evidentiary requirements. ▪ Experience with NCQA/HEDIS measure development or quality measurement frameworks. ▪ Proficiency with data platforms such as Optum Clinformatics, IBM...Full timeRemote work$33.28k
...as required • Adheres to all HIPAA, state and federal regulations pertaining to the clinical programs • Adheres to both URAC & NCQA standards in keeping with HealthHelp’s compliance initiatives • Carries out other projects and responsibilities as assigned...Full timeWork at officeLocal area$75k - $85k
...and version control — for external review or approval processes required by client or partner agreements (e.g., payor audits, URAC/NCQA-related documentation, SOC 2 evidence requests). Maintain documentation and status updates so stakeholders across Client Success...Full timeLive inLocal areaRemote workWorldwideFlexible hoursShift work$70k - $78k
...you’ll need: ~ Active RN Licensure ~2+ years experience in the process of Coverage Determinations in Healthcare ~ ~ NCQA and CMS standards for Utilization Management Authorization decisions LCD/NCD Coverage Determination Ability to conduct...Full timeTemporary workRemote workFlexible hours$83.2k - $93.6k
...HCPCS codes against medical record documentation Experience with hybrid measure abstraction and medical record review, including NCQA HEDIS, NCQA LTSS, and CMS Adult, Child, and LTSS Core Set measures Other Qualifications Technical aptitude and comfort...Part time$69.4k - $104.1k
...clients, payer representatives, and other cross-functional partners. ~ Ensure compliance with payer requirements, CMS guidelines, NCQA standards, delegated credentialing requirements, applicable regulations, and internal policies. ~ Maintain complete, accurate,...Full timeTemporary workWork at officeLocal areaRemote work$113k - $197.7k
...Strong financial background Knowledge of managed care industry, trends, and accreditation, including quality improvement and NCQA provider network requirements Ability to work independently and within a team environment Attention to detail and work plan...Hourly payFull timeContract workWork experience placementWork at officeLocal areaShift work$139.55k - $173.99k
...abstraction meet applicable external regulatory, accreditation, quality, and payer requirements, including HCAI, HCFA, The Joint Commission, NCQA, and other applicable data submission requirements. Accurately enters codes and abstracts clinical and demographic data into...Temporary workImmediate startRemote work$56.43k - $90.36k
...to conduct member, provider and community-based visits as needed to ensure effective administration of the program Adherence to NCQA and CMSA standards Perform any other job duties as requested Education and Experience: Nursing degree from an accredited nursing...Hourly payFull timeWork experience placementWork at officeLocal areaWork from homeHome officeFlexible hoursWeekend workAfternoon shift$86.93k - $107.38k
...Care Management Society of America (CMSA) and the established definitions of care management and care coordination published by CMSA, NCQA, TRICARE, and CMS. Applies evidence-based criteria, e.g., CMS, and HEDIS quality measures, for care management processes and...Full timeContract workRemote work$220k - $275k
..., quality incentives, outcomes-based contracts, or population health models ~ Familiarity with clinical quality metrics: HEDIS, NCQA, patient satisfaction, clinical outcomes, and cost-effectiveness ~ Strategic partnership development beyond traditional contracting...Full timeContract workLocal areaRemote work$72.2k - $115.5k
...stakeholders to facilitate collaboration and successful project outcomes. Assist other Quality & Performance Outcome teams with EQRO and NCQA readiness. Review pre-work and in-flight RFP opportunities and advise proposal writers in the content development in response...Hourly payFull timeWork experience placementWork at office
