Payer Delegation and Compliance Specialist Job at Anders Minkler Huber & Helm LLP (St. Louis)

Job Description

The Payer Delegation and Compliance Specialist at A5 Healthcare serves a critical role in ensuring that delegated healthcare tasks and responsibilities are executed in compliance with NCQA regulatory standards and organizational policies for the Primoris Independent Physician Association (IPA). This position is responsible for delegated credentialing, compliance monitoring, performance assessment, file audits and analysis, and improving the delegation processes to enhance client quality and operational efficiency. Communication and accountability in delegated functions are essential to meeting NCQA CR accreditation requirements.

Job Responsibility

Payer Delegation: NCQA standards (understand and identify changes necessary to comply with NCQA standards)
CAQH Application retrieval and review
File Audit and Analysis for inappropriate documentation and updates to credentialing information
Conduct qualitative analysis of inappropriate documentation and updates
Payer Rosters must be completed in accordance with A5’s policy and procedures
Credentialing Information Integrity
Policy and procedure (writing and updating in accordance with payer and NCQA standards)
Trouble shoot and problem solve implementation challenges related to NCQA standards, policy, and procedures
Evolution of system controls requirements
Team Collaboration: Communicate regularly with the non-delegated provider enrollment and CVO teams
Support teamwork balancing by assisting in complex case management and troubleshooting
Collaborate cross-functionally with internal stakeholders such as compliance, provider relations, and operations
General Responsibilities: Maintain in-depth knowledge of evolving payer policies, credentialing regulations, and accreditation standards
Analyze data and produce reports on credentialing metrics and trends
Participate in continuous improvement initiatives and credentialing software optimization
Promote a collaborative, high-performance culture in a fully remote or hybrid team environment

Requirements

Proven leadership ability and experience mentoring or training junior staff
Advanced understanding of CVO credentialing workflows, payer delegation requirements, and NCQA regulatory compliance
High-level organizational and problem-solving skills with keen attention to detail
Excellent written and verbal communication
capable of handling sensitive issues with professionalism
Proficient in credentialing and enrollment systems, with strong Excel and Microsoft Office Suite skills
Self-directed, accountable, and capable of managing priorities in a fast-paced remote environment
Associate’s degree required
Bachelor’s degree in healthcare administration or a related field preferred
Minimum 5 years of experience in delegation and compliance, payer enrollment or healthcare credentialing, including experience with NCQA, URAC, and CMS standards
Certification as a NAMSS Certified Provider Enrollment Specialist (CPES) is strongly preferred
Applicants must be located within the Greater St. Louis, MO area or Tulsa, OK

What we offer

Work Flex program which gives you the opportunity to work at our Chesterfield office, our Downtown St. Louis office, remotely, adopt a hybrid approach or even switch between these options as you prefer
Professional development opportunities
Benefits that directly impact mental, physical and financial wellness

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Payer Delegation and Compliance Specialist

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