External Quality Review (EQR) Specialists, PRN

Part-time As Needed

What you’ll do:

We are seeking Quality Review Specialists (specialists) to conduct external quality review activities as determined by health care quality review contracts. The specialists are responsible for timely interpretation and analysis of information provided to support contract compliance and quality improvement while maintaining positive professional working relationships with contract staff, program leaders, and health plans.

We expect you to:

• Assist with development of methodologies and data collection tools.
• Conduct desk and onsite document and program reviews.
• Interview staff during onsite visits and provide technical assistance as needed.
• Develop reports inclusive of findings and recommendations
• Providing technical expertise based on assessment and contract requirements.
• Provide maximum value to the customer.
• Serve as positive and supportive team member.
• Stay abreast of EQR requirements, state and federal regulations.
• Travel occasionally within the State of South Carolina.
• Works part-time on an as needed basis.

Who you are:

The successful candidate meets the following requirements:

• Degree from an accredited college or university in related field with at least 3 years of related experience
• Project Management, Utilization Management, Healthcare Quality or other certification preferred
• Knowledge of Medicaid managed care delivery systems and current healthcare trends
• Experience with Medicaid populations, programs, and policies
• Experience with Medicaid managed care or healthcare compliance
• Excellent communication skills to include report writing, development and delivery of content for health plan or provider education, website postings, and newsletter outlines
• Experience in quality management and improvement methodologies
• Demonstrated knowledge and understanding of Mental Health Parity
• Knowledge of URAC or NCQA accreditation standards and/or HEDIS certification a plus
• CPHQ a plus
• Knowledge of claims, credentialing, appeals & grievances a plus.

Why Constellation Quality Health

• We offer a competitive salary and a flexible, supportive work environment.
• Equal opportunity employer of protected veterans.
• Equal opportunity employer of individuals with disabilities.
• We do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, gender identity, national origin, medical condition, disability, veteran status, or any other basis protected by law.
• Applicants and employees are protected from discrimination based on inquiring about, disclosing, or discussing compensation or the compensation of other applicants or employees.