Job Summary
Evaluate and enforce policies and procedures to maintain the quality of claims documented in Outcomes programs, collaborate with internal stakeholders to identify and outline quality standards as they relate to projects and processes that pose potential risk for quality related issues or fraud, waste and abuse (FWA). Analyze data, reports, operating practices, and documentation as part of the standard monthly claims close and internal auditing processes to ensure quality in business processes.
Essential Duties & Responsibilities
- Demonstrate in-depth understanding of the business model, claim submission requirements and claim validation specifications
- Develop and manage an inventory of quality assurance system edits and coordinate with other departments to adjust, as needed
- Identify and resolve MTM activity issues and complete fraud, waste, and abuse monitoring by analyzing data, reports, operating practices, and documentation as part of standard monthly claims close and internal auditing processes to ensure compliance
- Develop and maintain network educational materials related to policies, procedures, and documentation requirements, including the policy and procedure guide
- Coordinate across departments to develop responses to client quality audits
- Strategize, execute, and monitor corrective action plans for quality related incidents
- Review daily data quality reports, identify inconsistencies and opportunities for improvement
- Provide quality assurance support across the business including reporting, processes and other areas as assigned
Qualifications
KNOWLEDGE & REQUIREMENTS
- Applies working knowledge in the application of concepts, principles and technical capabilities to perform varied tasks
- Works on projects of moderate scope and complexity
- Identifies possible solutions to a variety of technical problems and takes action to resolve
- Applies judgment within defined parameters
- Receives general guidance and may receive more detailed instruction on new projects
- Work reviewed for sound reasoning and accuracy
- Healthcare experience strongly preferred
- Ability to meet multiple deadlines
- Strong written and verbal communication skills
- Ability to communicate across all levels of an organization, demonstrating professionalism and good judgment at all times
- Must be able to work autonomously (with minimal direction) while also being part of an integrated team
- Must be able to manage competing demands and multiple priorities, while maintaining a strong attention to detail
- Strong quantitative, qualitative, and analytical skills including technical proficiency related to PC and basic office software
Education & Experience Requirements
- Minimum years of work experience: 2 years IN healthcare is preferred
- Minimum level of education or education/experience: Bachelors or equivalent work experience in healthcare operations, preferably Medication Therapy Management or member patient communications
Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job
- Frequent sitting in stationary position at a desk
- Occasional standing, walking, stooping, kneeling, squatting, and climbing stairs
- Occasional twisting of body
- Occasional reaching by extending hands and arms in any direction
- Occasional lifting, pulling, or pushing
What’s In It For You?
- Medical, Dental and Vision Plans
- Voluntary Benefits
- HSA & FSA
- Fertility and Family Planning Benefits
- Paid Parental Leave
- Adoption Assistance Program
- Employee Resource Groups
- Flex PTO for Exempt Associates and up to 15 PTO days in first year of employment for non exempt associates
- 11 Paid Holidays
- Corporate Wellness Program
- 401(k) plan offering both pretax and Roth contributions, plus an employer match
