Regulatory & Quality Oversight Specialist -- WVPHO ADMINISTRATION -- Northgate-400 Association Dr.

Job Summary

The Regulatory & Quality Oversight Specialist ensures that Payer Enrollment and affiliated functions maintains compliance with CMS, Medicaid, Medicare Advantage, and commercial payer requirements. This role conducts audits, monitors error trends, supports survey readiness, and ensures enrollment and revenue cycle processes are aligned with regulatory and accreditation standards.

Responsibilities

• Perform audits of payer enrollment submissions, provider files, and roster reconciliations to ensure compliance with regulatory and NCQA and payer requirements.
• Track and report quality metrics, including enrollment turnaround times, error rates, and compliance with NCQA credentialing timelines.
• Support NCQA accreditation activities by maintaining policies, documentation, and audit tools.
• Collaborate with the VPHO leadership to ensure daily workflows meet quality and compliance standards.
• Monitor changes in regulatory and accreditation requirements and advise leadership on operational impacts.
• Assist in preparing for payer or accreditation audits by gathering documentation and responding to requests.
• Partner with Revenue Cycle and Value-Based Care teams to ensure that enrollment data accuracy supports claims processing, authorizations, and member attribution.
• Recommend corrective actions and process improvements based on audit findings.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department's identified patient ages.

Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Competency Statement

Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.

Common Duties and Responsibilities

(Essential duties common to all positions)

1. Maintain and document all applicable required education.

2. Demonstrate positive customer service and co-worker relations.

3. Comply with the company's attendance policy.

4. Participate in the continuous, quality improvement activities of the department and institution.

5. Perform work in a cost effective manner.

6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.

7. Perform work in alignment with the overall mission and strategic plan of the organization.

8. Follow organizational and departmental policies and procedures, as applicable.

9. Perform related duties as assigned.

Education

Bachelor's degree in healthcare administration, business, or related field preferred (Associate degree with experience acceptable).

• 3-5 years of experience in payer enrollment, credentialing, or healthcare compliance.
• Strong knowledge of CMS, Medicaid, and commercial payer enrollment requirements.
• Working knowledge of NCQA credentialing standards and accreditation readiness processes.
• Experience in audit preparation, compliance monitoring, or quality assurance.
• Strong analytical, reporting, and communication skills.

Work Schedule: Days

Status: Full Time Regular 1.0

Location: Northgate-400 Association Dr.

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Tamara B. Young tammy.young@vandaliahealth.org