3 Ncqa Jobs

As a Data Analyst with deep experience in the US Healthcare industry and skills around Machine Learning (ML), you will play a vital role in conducting comprehensive data analysis using statistical and exploratory methods to uncover patterns and insights that drive data-driven decision-making in the healthcare domain. Leveraging your knowledge of healthcare industry metrics such as HEDIS, CMS Star Ratings, risk adjustment models, and revenue cycle data, you will optimize analytics strategies to ensure efficient data quality, availability, and reliability for AI/ML-driven healthcare analytics solutions. Your responsibilities will include designing and maintaining data pipelines for the ingestion, transformation, and storage of claims, electronic health records (EHR), HL7/FHIR data, and real-world evidence (RWE) while ensuring compliance with HIPAA, PHI, and other regulatory requirements. Collaborating closely with data science and engineering teams, you will develop and maintain dashboards and reports that translate complex healthcare data into actionable insights for business stakeholders using visualization tools such as Streamlit, Snowflake, Power BI, or similar platforms. You will apply your expertise in healthcare cost, quality, and operational performance analytics to deliver meaningful insights and work closely with cross-functional teams, including data science, engineering, API development, and healthcare operations, to understand data needs and deliver tailored solutions. Additionally, you will engage with industry experts, attend relevant healthcare and data science conferences, and contribute to continuous learning within the team to enhance process understanding and ensure data accuracy for regulatory and business reporting. To excel in this role, you should have strong proficiency in SQL and Python, including libraries such as pandas for data manipulation and analysis. Experience with healthcare data visualization and storytelling tools, familiarity with ETL pipelines, data warehousing, and cloud platforms (AWS, Azure, GCP) for healthcare data processing, as well as knowledge of healthcare standards and regulations are essential. Experience in revenue cycle management (RCM), medical coding (ICD, CPT, DRG), and healthcare cost/utilization analytics is a plus, along with the ability to analyze complex healthcare datasets and derive meaningful insights impacting operational efficiency, patient outcomes, and cost optimization. Excellent communication and stakeholder management skills, with the ability to translate technical findings into business insights, are key to collaborating effectively with healthcare business teams, IT, and data science professionals. A curious mindset and willingness to explore new challenges and drive innovation in healthcare analytics are also important qualities for success in this role.,

POSITION SUMMARY The Senior MD Analyst is responsible for supporting the development and design of clinical information systems and treatment protocols for the deployment of ZeOmega's Jiva platform. The role is responsible of abstraction, analysis and submission of clinical data. This position will work on the quality and coordination of data collection, entry, analysis, submission, report preparation, presentation of data, data sharing for process improvement initiatives, bench marking and outcomes research. This position communicates the report findings to others throughout the organization, including recommendations for improvements and focused studies. Works in partnership with ZeOmega leadership personnel in research, system configuration and testing, implementation, and translation of clinical requirements into specifications for clinical protocols. PRINCIPLE JOB RESPONSIBILITIES: Provides precise input into the development of clinical rules supporting identification, care management plans, potential gaps in care, and protocol research, as well as the design of the clinical system, features supporting protocol management, and the use of the system to leverage the clinicians' time and maximize communication among stakeholders • Identify new ways to ensure that the data and metrics supporting our operational decisions is accurate and timely Provides analysis of regulatory and guidelines changes in the industry, e.g., HEDIS, Stars, NCQA, URAC, and applicability to product configurations and new development • Lead in providing the broad-based and in-depth input regarding the design of the clinical information system protocols Collaboration leadership within the team and cross-functional teams to design clinical systems to support excellence in patient care plans Reviews medical informatics trends, experiences, and approaches to develop clinical/technical and application implementation strategies and protocols. • Works in a cross-functional team with Business Analysts (BA) and Subject Matter Experts (SME) to design and implement systems supporting care management and physician engagement regimens. Collaborate with analytics and operational leaders to develop insights that will drive better understanding of patient utilization and cost drivers • Facilitates the design of clinical pathway models with a physician, nursing, and administrative leadership, and will assist in modification and annual review of these models to gain maximum efficacy Participates in the development and deployment of solutions that cluster information in disease and episodic categories for benchmarking, clinical severity, and variance analysis Lead the design and evaluation of collection of data for clinical purposes, including tracking and interpretation of outcomes • Participates in determining content and design of care management and provider reports • Conduct worldwide medical/clinical literature, regulatory, and program research to develop innovative health promotion and medical/behavioural health management programs Experience: 10+ years of experience in relevant technology and industry. Education: MBBS Skills: HEDIS and/or Stars knowledge preferred. • US Healthcare experience preferred. • Expertise in US Managed Health and/or ACO delegated care management preferred. • Clinical analysis from regulations (Medicare and Medicaid) and nationally recognized guidelines (NCQA, URAC) and standards preferred. • Familiarity with evidence-based clinical protocol development required. • Knowledge of machine learning and artificial intelligence in clinical analytics preferred. • Knowledge of patient engagement and digital engagement strategies. Proven collaboration and communication skills within a cross-functional team environment.

Overview: As a Credentialing Executive, you will play a crucial role in ensuring that our healthcare organization maintains compliance with regulatory standards and delivers high-quality care by thoroughly vetting and credentialing healthcare providers Your attention to detail, understanding of healthcare regulations, and ability to build strong relationships will be instrumental in facilitating the credentialing process and maintaining accurate provider databases. Responsibilities: Provider Credentialing: Manage the credentialing process for healthcare providers, including physicians, nurse practitioners, physician assistants, and allied health professionals This involves collecting, verifying, and evaluating provider credentials, licenses, certifications, and other relevant documents to ensure compliance with organizational and regulatory standards. Provider Enrollment: Coordinate provider enrollment with various insurance networks, Medicare, Medicaid, and other payer organizations Complete and submit enrollment applications accurately and in a timely manner to facilitate reimbursement for services rendered by credentialed providers. Database Management: Maintain accurate and up-to-date provider databases, including credentialing files, licensure information, malpractice insurance coverage, and other pertinent documentation Ensure that all provider information is entered and updated in credentialing software systems or databases. Regulatory Compliance: Stay abreast of changes in healthcare regulations, accreditation standards, and payer requirements related to provider credentialing and enrollment Ensure that credentialing processes align with industry best practices and regulatory guidelines, including those set forth by organizations such as NCQA, URAC, and CMS. Provider Relationships: Develop and maintain positive relationships with healthcare providers, medical staff, and internal stakeholders to facilitate the credentialing process Serve as a liaison between providers and credentialing committees, addressing inquiries, resolving issues, and providing support as needed. Quality Assurance: Implement quality assurance measures to monitor the effectiveness and efficiency of the credentialing process Identify areas for improvement and implement corrective actions to enhance process efficiency, accuracy, and compliance. Audits and Reviews: Prepare for and participate in internal and external audits, reviews, and accreditation surveys related to provider credentialing and enrollment Ensure that credentialing documentation and processes meet audit requirements and support organizational compliance. Training and Education: Provide training and education to healthcare providers and staff on credentialing policies, procedures, and best practices Foster a culture of compliance and accountability throughout the organization by promoting awareness of credentialing requirements and expectations. Qualifications: Bachelor's degree in healthcare administration, business administration, or a related field (Master's degree preferred). Certification in healthcare credentialing (e.g., CPCS, CPMSM) highly desirable. Minimum of 3-5 years of experience in healthcare credentialing and provider enrollment, preferably in a managed care. In-depth knowledge of healthcare regulations, accreditation standards, and payer requirements related to provider credentialing and enrollment (e.g., NCQA, CMS, Medicare). Proficiency in credentialing software systems (e.g., CAQH, NAMSS) and Microsoft Office Suite. Strong analytical skills with the ability to review and interpret complex credentialing documents and data. Excellent communication, interpersonal, and organizational skills. Detail-oriented with a commitment to accuracy and quality assurance. Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment.