System Controls: Utilization Management & Credentialing
Date: Wednesday, August 3, 2022; 2-4pm ET
System Controls: Utilization Management & Credentialing – NCQA Accreditation 2022
The System Controls requirements for Health Plan Accreditation aim to uphold the integrity of utilization management and credentialing systems and processes. Through this session, NCQA staff will address the new System Controls requirements for the 2022 Health Plan Accreditation Utilization Management and Credentialing Standards.
Course topics are not exclusive to NCQA requirements but are applicable to NCQA requirements for Health Plan Accreditation. Participants are expected to have a working knowledge of utilization management, credentialing, and policies and procedures for Health Plan Accreditation.
• Denials and Appeals for Utilization Management
• System Control Monitoring
• System Control Oversight
• Delegation and Automatic Credit
• Presentation Slides
• Recording of Live Session
• Live Q&A
• Scenarios for Applied Learning
• Perspective from Former NCQA Staff
- Clinicians and staff at health plans.
- Contributors of NCQA Surveys for Health Plan Accreditation.
- Delegates and vendors of health plans.
- Professional who led multidisciplinary teams.
• Describe the intent of the System Controls Standards for Utilization Management and Credentialing.
• Distinguish key differences between 2021 and 2022 System Controls Standards for Utilization Management and Credentialing.
• Summarize new requirements in the 2022 System Controls Standards for Utilization Management and Credentialing.
• Analyze the new System Controls Oversight requirements for Utilization Management and Credentialing.
• Explain the scope of delegation and automatic credit requirements.
Melina Bowdwin, MPH
is a Policy Manager at the National Committee for Quality Assurance (NCQA). She assists in policy clarification and annual updates to NCQA’s accreditation programs. Prior to joining NCQA, Ms. Bowdwin was Assistant Director at Island Peer Review Organization (IPRO), where she conducted activities related to external quality review for Medicaid managed care programs across the country. She holds a Master of Public Health degree from University at Buffalo (SUNY), with an emphasis on Community Health and Health Behavior.
Joy Park, MPH, PMP
Joy Park is a Policy Manager in Accreditation Policy at the National Committee for Quality Assurance (NCQA). She develops and maintains Utilization Management standards in NCQA products and clarifies policies for internal and external customers. Ms. Park previously worked in the Quality Solution Group at NCQA, providing project management and analytic support for federal and state contracts. She holds a BS in Health Promotion and Behavior from The University of Georgia and an MPH in Health Policy and Management from Emory University.
Julie Pung, MBA
Julie Pung is an Assistant Director in Accreditation Policy at the National Committee for Quality Assurance (NCQA). She oversees NCQA’s Policy Clarification Support System (PCS) which provides interpretation on NCQA accreditation and certification standards and guidelines. She also oversees development of NCQA accreditation and certification standards and guidelines, Policy updates & clarifications and accreditation policy surveyor education. Prior to joining NCQA, Ms. Pung was Director, Enterprise Quality and Accreditation at Health Care Service Corporation (HCSC) where she oversaw NCQA Health Plan Accreditation for BCBS of Illinois, BCBS of New Mexico and BCBS of Texas and URAC Utilization Management Accreditation for BCBS of Illinois and BCBS of Texas. She holds a Bachelor of Arts degree in Psychology from Kalamazoo College and Master of Business Administration in Healthcare Management from Lake Forest Graduate School of Management.
Gerald Stewart, MHA
Gerald Stewart is a health quality improvement practitioner with a Master’s in Health Administration and certification as a Six Sigma Master Black Belt. Gerald has over 25 years of experience in helping improving business processes to deliver value and better experience and outcome for customers. Gerald has led the production, management and optimization accreditation and certification products for the National Committee for Quality Assurance (NCQA) and has served as a subject matter expert and NCQA surveyor since 2001. Gerald has successfully served in several quality assurance/improvement roles (worn many hats) from NCQA project manager, corporate enterprise quality director, to assistance vice president of operations. For all of them and for whatever comes next, Gerald has been and remains unpretentiously obsessed with Making-It-Better and using the talented people to accomplish better. There is nothing more rewarding in life than knowing that you have help make a positive difference in another human being.
This live course grants 4.0 Other Continuing Education Unit (CEU) points for PCMH Certified Content Experts.
* Please note – You must attend the entire program to be eligible for total number of contact hours.
Disclosure of Relevant Financial Relationships
The National Committee for Quality Assurance (NCQA) endorses the Standards of the Accreditation Council for Continuing Medical Education which specify that sponsors of continuing medical education activities and presenters at and planners for these activities disclose any relevant financial relationships either party might have with commercial companies whose products or services are discussed in educational presentations.
For sponsors, relevant financial relationships include large research grants, institutional agreements for joint initiatives, substantial gifts, or other relationships that benefit the institution. For presenters or planning committee members, relevant financial relationships include the receipt of research grants from a commercial company, consultancies, honoraria, travel, or other benefits, or having a self-managed equity interest in a company; or having an immediate family member or partner with such a relationship.
Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation.
Relevant financial relationships exist with the following companies/organizations:
Melinda Bowdwin: None
Joy Park: None
Julie Pung: None
Gerald Stewart: None
Additional Planning Committee Members:
Vincent Pereira: None
This program was developed in part by NCQA staff.
This program received no commercial support.
- 1.00 Participation
- 4.00 PCMH CCE