Provider Network Audit Specialist_PN

Provider Network Audit Specialist

Who are we?

Versant Health is one of the nation’s leading administrators of managed vision care, serving millions of our clients’ members nationwide. We are driven by our mission to help members enjoy the wonders of sight through healthy eyes and vision.

As a Versant Health associate, you can enjoy a comprehensive Total Rewards package, which includes health and dental insurance, tuition reimbursement, 401(k) with company match, pet insurance, no-cost-to-you vision insurance for you and your qualified dependents. We are also invested in your success. There are many opportunities for advancement and development throughout all stages of your career with us.

See how you can make a difference with the support of strong leadership and a team environment.

See Everything, Be Anything™.

What are we looking for?

The Provider Network Audit Delegation Specialist role is a key member of the Network Operations Team, directly responsible for Versant Health’s Provider Network and Credentialing Audit Programs, to include audit performance, reporting, corrective actions, and presenting to internal department and external auditors; and Versant Health Network’s ability to maintain compliance with Federal, State, Accreditation, and SOC 1 regulatory requirements. Interface with delegated groups, complete required auditing and reporting related to delegation, and ensure adherence with NCQA requirements for assigned function.

Where you will have an impact

Conduct delegated audits for assigned function and communicate reporting requirements and related activities to delegated entities

Ensure compliance with delegation monitoring and oversight requirements for assigned function

Assist in managing policies and procedures relating to delegation maintenance and ensure successful delegation partnerships and department quality

Report audit outcomes and delegation monitoring results to management

Principal for conducting Network Operations’ System and Organization Controls (SOC) 1 Control Audits. Directly responsible for audit performance, measurements, remediations, and reporting to Network Operations and Support Leadership and Compliance Management. Presents SOC 1 Controls and audit methodology to internal and external Auditors.    

Directly responsible for all audit activities relating to Provider Network’s and Credentialing’s health plan and client delegation oversight audits and accreditation surveys; lead Provider Network’s reporting, communications, and presentations to health plans and clients during delegation oversight audits; manage and resolve all issued corrective action plans (CAPs) from health plans and clients.

Principal for conducting Provider Network’s On-Going Exclusion Screening and Monitoring program; ensure CMS participation guidelines are followed and all provider network entities are screened against the Preclusion List, LEIE (List of Excluded Individuals Entities), General Services Administration (GSA), Excluded Parties List System (EPLS), now part of GSA’s System for Award Management (SAM); receives and responds to all Health Plan requests.

Directly responsible for all Network Operations and Support Department Policies and Procedures, to include policy creation, annual reviews, revisions, and maintenance with Federal and State regulatory requirements.

Generates and distributes Provider Network Operations analytical reports, compliance reports, interprets results, and identifies trends and recommendations to Network Operations and Support Leadership

Ensures compliance with the National Committee for Quality Assurance (NCQA) and Versant Health’s credentialing standards.

Review discrepancies in reports and provider data received, request clarification from providers, health plans, and clients; advise Network Operations Leadership

Interact with departmental and other department staff on matters affecting provider data flow; make recommendations for improvement or enhancement to job processes to ensure standards in Versant Health data entry management and collection.

Coordinate Level-One and Level-Two Credentialing Appeals Hearings. This includes coordinating and scheduling the Appeal Hearing with the appealing Provider and the Credentialing Appeals Committee, taking Hearing Minutes, scheduling the Appeals Hearing Committee’s vote, and notifying the appealing Provider of the Credentialing Committee Appeals Hearing outcome.      

What’s necessary to do the job?

Bachelor degree in related field preferred or equivalent combination of experience and education

Five to seven (5-7) years of experience years with a managed care organization in a Network Management, Credentialing, Provider Data Management, and/or Provider Relations role.  

Significant experience in with NCQA and  URAC standards for Credentialing and Recredentialing, and Network.

Capable and comfortable dealing with Protected Health Information (PHI), Personal Identifiable Information (PII), sensitive, and confidential information with discretion and trust

Advance proficiency in Microsoft Excel and proficiency with Mircosoft Office programs including Word,  Access, Power Point and Microsoft SharePoint

HIPAA & Security Requirements

All Associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI) as described in the Notice of Privacy Practices and HIPAA Privacy Policies and Procedures. As a component of job roles and responsibilities, Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times. As a result, Associates must explicitly adhere to all data security guidelines established within the Company’s Privacy & Security Training Program.

Versant Health will never request money from candidates who seek employment with us and will never ask for any payment as part of the recruitment process.

Versant Health is a proud Equal Employment Opportunity and Affirmative Action employer dedicated to attracting, retaining, and developing a diverse and inclusive workforce. All qualified applicants will receive consideration for employment at Versant Health without regards to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law.

The wage range for applicants for this position is [$25.00 to $25.50].

All incentives and benefits are subject to the applicable plan terms.