Accreditation Quality & URL Specialist II

Exemption Status:

United States of America (Exempt)

$68,571 - $93,600 - $118,628

“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors.  A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”

This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description

Summary

Responsible for the execution of the annual accreditation, clinical quality, and UR licensure assessment processes and work plans required to obtain and maintain MedImpact's NCQA and URAC accreditations and state UR licensure requirements across all lines of business, including Commercial, Medicare, Medicaid, and Marketplace.  Applies healthcare and clinical quality expertise to accreditation readiness, delegation oversight, committee support, and ongoing quality monitoring activities.  Coordinates with internal partners, delegated

entities, and client-facing teams to accomplish assigned accreditation, clinical quality, and compliance activities.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

Performs accreditation, quality, and utilization management related audits and activities with an emphasis on obtaining or maintaining NCQA and URAC accreditation and multi-state UR licensure.

Participates in onsite audits/reviews, agency inquiries, and training employees, as needed.  Supports responses to accreditor, regulator, and client audits, inquiries, and documentation requests.  Performs ongoing monitoring to ensure the organization is meeting accreditation, regulatory, and contractual standards.

Analyzes data, case files, workflows, policies and procedures to assess program effectiveness.  Interprets significance of routine-intermediate findings to identify areas of improvement, make and implement recommendations for improvement, and track corrective actions to closure.

Defines and documents accreditation and compliance process steps (i.e., policy and procedures) in accordance with current state, federal, and independent accreditation and UR licensing requirements.  Maintains assigned policies and procedures within the enterprise document management system in accordance with annual review requirements.

Communicates and consults with internal partners, delegated entities, and client-facing teams to assist with the implementation of accreditation, clinical quality, and compliance recommendations for assigned area(s).

Serves as accreditation subject-matter expert for NCQA and/or URAC standards and for all or specific program sections, to consult and update internal partners on accreditation efforts and requirements.  May recommend and provide training to employees regarding accreditation and compliance requirements and procedures.

Stays current with accreditation standard updates, state legislative activity, and regulatory requirements, as well as PA/UM and Appeals programs to consult and provide a mutually beneficial resolution.

Performs pre-delegation evaluations and supports ongoing delegation oversight activities, including annual delegate monitoring and review of delegation agreements and responsibility matrices against currently applicable accreditation standards.

Prepares accreditation, clinical quality, and utilization management reporting for quality and utilization management oversight committees, including agendas, materials, minutes, and tracking of assigned action items through closure.

Supports client-facing accreditation and quality deliverables, including requests for proposal (RFP) responses, delegation agreement inquiries, and client audit support, in coordination with account management.

Serves as a primary departmental resource for URAC Pharmacy Benefit Management accreditation requirements, including evidence development, annual and interim reporting, and ongoing compliance monitoring.

Other duties as assigned.

• Supervisory Responsibilities
• No supervisory responsibilities
• Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Education and/or Experience
• BS/BA and 5+ years’ experience or equivalent combination of education and experience, and 3 years of SME within a PBM, Managed Care, provider setting in addition to direct experience in clinical quality, utilization management or accreditation. Demonstrated subject-matter expertise with NCQA and/or URAC standards, including survey preparation, evidence and documentation development, and file review, is required. Direct experience working with URAC Pharmacy Benefit Management (PBM) accreditation standards is highly preferred.
• Computer Skills
• Microsoft Office Suite (Word/Excel/Access/Outlook),Teams and standard PDF document tools, including the ability to create, combine, annotate, and complete fillable PDF documents. Working knowledge of enterprise document management, prior authorization, appeals, and quality reporting systems is preferred.
• Certificates, Licenses, Registrations
• Based on the clinical nature of the work, an unencumbered healthcare related license is required.  Examples of applicable licenses include Pharmacy Technician (CPT), Medical Assistant (MA), and/or Registered Nurse (RN).
• Healthcare quality or accreditation-related certification, such as Certified Professional in Healthcare Quality (CPHQ), is preferred.
• Other Skills and Abilities
• Demonstrated experience leading operational projects from inception to completion, ensuring objectives, timelines, and deliverables are achieved.
• Ability to collect and analyze requirements while creating and managing detailed project plans to support accreditation and quality management activities.
• Excellent interpersonal and relationship-building skills, with the ability to contribute independently and within a team environment.
• Proven flexibility and adaptability in responding to changing deliverables, priorities, and timelines.
• Working knowledge of prior authorization, appeals, and utilization management processes, including applicable federal and state regulatory requirements.
• Strong written and verbal communication skills, including preparation of audit findings, committee materials, and client-facing documentation.
• Experience managing competing priorities and concurrent workstreams related to accreditation, licensure, and audits while ensuring accuracy, compliance, and timely completion, with minimal supervision.
• Reasoning Ability
• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.

This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes, or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples: business office with computers and printers, light traffic).

Work Location

This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements). Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.

Working Hours

This is an exempt level position requiring the incumbent to work the hours required to fully accomplish job responsibilities and meet deadlines for work deliverables. The individual must have the flexibility to work beyond traditional hours and be able to work nights, weekends or on holidays as required. Work hours may be changed from time to time to meet the needs of the business. Typical core business hours are Monday through Friday from 8:00am to 5:00pm.

Travel

This position requires no travel; however, attendance may be required at various local conferences and meetings.

The Perks:

• Medical / Dental / Vision / Wellness Programs
• Paid Time Off / Company Paid Holidays
• Incentive Compensation
• 401K with Company match
• Life and Disability Insurance
• Tuition Reimbursement
• Employee Referral Bonus
• To explore all that MedImpact has to offer, and the greatness you can bring to our teams, please submit your resume to www.medimpact.com/careers

MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

Equal Opportunity Employer, Male/Female/Disabilities/Veterans

OSHA/ADA:

To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.