Quality Analyst/Auditor
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Job Summary
The Quality Analyst/Auditor manages quality-related aspects of insurance contracts to ensure Prevea Health receives negotiated reimbursements for meeting required quality metrics. This position reviews medical records, analyzes payer data, and collaborates with providers and leadership to ensure accurate documentation, compliance, and optimization of quality performance tied to insurance contracts.
What you will do
- Review medical records and extract relevant data to meet quality and audit metrics; verify accuracy of documentation and coding. Review reports and data provided by insurance payors; perform audits and medical record validation to ensure accuracy.
- Assist with implementation of new contracts and programs, ensuring workflows and processes meet contract requirements related to quality metrics.
- Develop educational materials and provide guidance to providers and staff related to quality metrics, documentation standards, and contract requirements.
- Support contract review by analyzing quality-related terms within assigned insurance contracts and amendments; interpret and communicate quality measure requirements and performance thresholds to support achievement of contract goals
- Prepare audit reports and streamline workflows to meet monthly, quarterly, and annual quality and performance goals.
- Monitor assigned contract performance to identify gaps in meeting quality requirements; recommend and support corrective actions as needed.
- Identify and support opportunities for automation of quality data extraction using EPIC or other data sources.
- Collaborate with Clinical Optimization Team, Chief Quality Officer, Chief Financial Officer, and Physicians/Clinicians to develop and implement best practices for quality-related workflows.
Education Qualifications
- Associate's Degree Healthcare Administration or Technical Diploma in Healthcare related field Preferred
Experience Qualifications
- 2+ years Healthcare related work experience Required
- Clinical experience as MA or LPN Preferred
- Experience with electronic medical records, EPIC, and Microsoft Office Preferred
Skills and Abilities
- Familiarity with quality measures such as HEDIS.
- Understanding of medical record documentation and coding guidelines.
- Knowledge of medical insurance claims processes.
- Familiarity with insurance contracts.
- Strong analytical, auditing, and organizational skills.
- Ability to communicate effectively with providers, leadership, and cross-functional teams.
Physical Demands
- Sit - Constantly
- Stand - Rarely
- Walk - Rarely
- Drive - Rarely
- Climb (Stairs/Ladders) - Rarely
- Bend (Neck) - Constantly
- Gross Manipulation (Hands/Arms) - Occasionally
- Twist/Turn (Neck) - Frequently
- Twist/Turn(Waist) - Occasionally
- Lift/Carry 0-10 lbs. - Occasionally
- Lift/Carry 11-25 lbs. - Rarely
- Lift/Carry 26-35 lbs. - Rarely
- Push/Pull up to 10 lbs. - Rarely
- Push/Pull 11-25 lbs. - Rarely
- Push/Pull 26-35 lbs. - Rarely
- Reach (Above shoulder level) - Rarely
- Reach (Below shoulder level) - Frequently
- Simple Grasping (Hands/Arms) - Frequently
- Fine Manipulation (Hands/Arms) - Frequently
- Gross Manipulation (Hands/Arms) - Occasionally
Working Conditions
Travel Requirements
Hearing Requirements
- Hears Whispers < 3 feet - Constantly
- Hears Whispers 3-8 feet - Constantly
Vision Requirements
- Color Discrimination - Constantly
- Near Vision (Correctable to Jaeger 2 or 20/40 binocular) - Constantly
- Distance Vision (Correctable to Snellen chart 20/40 binocular) - Constantly
Prevea is an Equal Employment Opportunity/Affirmative Action employer. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United State and to complete the required employment eligibility document form upon hire. Prevea participates in E-verify. To learn more about E-Verify, including your rights and responsibilities, please visit www.dhs.gov/E-Verify