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Quality Review Specialist
, , | Full-time
Apply by:
May 4, 2025
POSITION: Quality Review Specialist
DEPARTMENT: Provider Relations
Base Rate: $19.83 per hour, with potential for additional compensation based on qualifications.
POSITION SUMMARY:
The Provider Relations Quality Review Specialist ensures the accuracy and integrity of provider data in UPHP’s provider database management system and across all member and provider-facing resources, including printed directories and online search tools. This role plays a key part in maintaining compliance with organizational standards and regulatory requirements related to provider network submissions, quality reporting, and audit processes. The Quality Review Specialist supports member access to care and promotes network adequacy by safeguarding the quality of UPHP’s provider information.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.
2. Ensures provider data in UPHP’s provider management database is accurate, complete, and updated timely and in accordance with contracting and credentialing policies and processes.
3. Ensures network providers meet Medicaid and Medicare eligibility and enrollment requirements, including, but not limited to, Community Health Automated Medicaid Processing System (CHAMPS) enrollment, Medicare eligibility requirements and Medicare preclusion list.
4. Responsible for development, maintenance, accuracy, and oversight of print and web-based provider directories and search tools for all product lines.
5. Ensures compliance with model documents and guidance issued by the Centers for Medicare and Medicaid Services (CMS), the State of Michigan Department of Health and Human Services (MDHHS), and the National Committee for Quality Assurance (NCQA) to support network adequacy and member access to care.
6. Evaluates web-based provider directories for understandability and usefulness to members and prospective members at least every three years including, but not limited to, reading level, intuitive content organization, ease of navigation, and additional languages if applicable.
7. Facilitates provider satisfaction surveys to meet NCQA and contractual requirements and supports initiatives to maintain or improve provider satisfaction.
8. Supports quality management and company-wide quality initiatives such as Healthcare Effectiveness Data and Information Set (HEDIS®), Consumer Assessment of Health Plans (CAHPS), and NCQA.
9. Creates reports to evaluate and monitor member access and availability and to meet network adequacy requirements for all product lines. Conducts necessary outreach and completes exception requests as appropriate.
10. Supports processes to ensure access and availability of providers, including, but not limited to, secret shopper surveys, after-hour surveys, and any additional initiatives, outreach, and follow-up as appropriate.
11. Conducts audits to ensure initial credentialing and recredentialing files are complete and meet timeliness and quality standards.
12. Supports compliance processes, including, but not limited to, provider site visits and documenting compliance actions and findings in the provider management database.
13. Maintains confidentiality of client data.
14. Performs other related duties as assigned or requested.
POSITION QUALIFICATIONS:
Education:
Minimum:
Associate degree in health information processing or related field.
Preferred:
Bachelor’s degree in business, health information processing, health information systems or
related field.
Experience:
Minimum:
One (1) year of experience in managed-care or related health-care setting
Preferred:
Experience in managing provider demographic data and experience with provider management database(s)
Required Skills:
Proficient in Microsoft Office (Word, Excel, and Outlook)
Attention to detail and analytical skills
Excellent human relation and oral/written communication
Excellent organizational and prioritization abilities
Desired Skills:
Proficient in MS PowerPoint
Familiarity with CMS, NCQA, and MDHHS standards
Understanding of healthcare provider networks and regulatory requirements
The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria.
Physical Requirements:
[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:
Ability to access departmental files
Ability to enter and access information from a computer
Ability to access all areas of the UPHP offices
Occasionally lifts supplies/equipment
Prolonged periods of sitting
Manual dexterity
Working Conditions:
Works in office conditions, but occasional travel may be required
Exposure to situations requiring exceptional interpersonal skills or periods of intense concentration
Subject to many interruptions
Occasionally subjected to irregular hours
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