UnityPoint Health Credentialing Quality Assurance Auditor in West Des Moines, Iowa
Under the direction of the Quality Assurance Manager and in collaboration with the Credentials Verification Office (CVO) and Physician Hospital Organization (PHO)/Medimore, the Quality Assurance Auditor performs audits of credentialing files completed by both the CVO and PHO. Communicates audit results to the relevant team for follow up and correction. Adheres to the highest standards of credentialing review to ensure compliance with all legal, regulatory, and accreditation requirements, as well as best practice credentialing tasks identified by UnityPoint Health.
Credentialing File Auditing
Responsible for auditing complete credentialing applications and building sound, effective and efficient audit process.
Completes initial and ongoing quality audits for credentialing while providing constructive feedback and education to peers and assigned teams
Perform audit reviews in a timely, efficient, and accurate manner to ensure compliance with relevant accreditation and regulatory standards and internal policies and procedures.
Utilize basic audit skills and practices to identify, document, test the effectiveness of internal processes and controls and develop sound conclusions.
Review, utilize auditing tools and critical thinking skills to identify gaps and/or errors in credentialing files ensuring it applies to NCQA, TJC, DNV, CMS, Federal, State and all other requirements.
Analyze credentialing files for completeness, accuracy, consistency, gaps in work history, relevant references, etc.
Identify issues and initiate further data collection as needed.
Track and trend audit and notify leadership to administer appropriate team members education and coaching.
Manage multiple concurrent audits, plan audits, and related projects.
Execute audit planning by performing research to assist in development of appropriate audit scope, audit programs, and testing procedures.
Communicate effectively both orally and in writing sound conclusions supported by audit evidence and make recommendations to strengthen internal controls and increase efficiency, effectiveness and economy of operations.
Perform regular follow-up and review in accordance with UPH management in accordance with identified audit procedures to corrections are completed within agreed upon timeframes. Ensure completed corrections are evidenced to support the completed status.
ontinuous Process Improvement
Build and maintain collaborative relationships with CVO and PHO team members, stakeholders, and leadership at both the System Services and regional affiliate levels.
Participate in workgroups as requested advising on system-wide credentialing matters.
Utilize system software to efficiently research, document and test areas of risk.
Facilitate departmental process enhancement initiatives.
Maintain a high level of organization and planning in order to complete assigned projects within designated timeframes.
Research and utilize outside resources to maintain and update knowledge of healthcare and audit issues.
Basic UPH Performance Criteria
Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
Demonstrates ability to meet business needs of department with regular, reliable attendance.
Employee maintains current licenses and/or certifications required for the position.
Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
Completes all annual education and competency requirements within the calendar year.
Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.
High school graduate or GED equivalent.
Minimum of 2 years of experience in the field of CVO Operations, PHO operations, auditing, primary source verification, or quality practices:
Knowledge of the healthcare industry.
Proficient in Microsoft Office Suite.
Knowledge of regulatory agency standards (i.e., NCQA, URAQ, The Joint Commission, DNV, etc.).
One year of credentialing auditing experience or similar
Excellent communication skills both written and verbal.
CPCS certified or must obtain within one year of eligibility.
Work with sensitivity with confidential information on a continuous basis
Proficiently use MS Office, including Word, Excel, PowerPoint, and Access (including ability to manage databases, develop charts, tables, graphs)
Communicate well with a range of leaders and employees
Employ excellent analytical abilities and to problem-solve
Be well organized, attentive to detail, meet established deadlines, and work well under pressure
Requisition ID: 2021-99240
Street: 1776 West Lakes Pkwy
Name: 9010 Administration
Name: Credentials Verification Org
FTE (Numeric Only; Ex. 0.01): 1.0
FLSA Status: Non-Exempt
Scheduled Hours/Shift: 7a - 4:30p
External Company URL: http://www.unitypoint.org