This key role will be responsible for analyzing operational processes to drive quality improvement throughout the Operation. The Operations Quality Analyst is responsible for defining, managing, verifying, and reporting key quality KPIs/metrics for various aspects of the business. These Metrics will help drive business functions and identify key areas for process improvement. The Analyst will coordinate data collection and reports of various operations function to ensure they are accurate and compliant with relevant law, regulations, process and procedures. Ideal candidates will maintain a broad knowledge of corporate Claims Processing, Enrollment, Government Programs, regulations and regulatory guidelines for use in conducting Quality Control, Quality Assurance and Operational Improvement. Major focus on the role will include creation of data visualizations, reports, and dashboards for internal and external use.
KEY FUNCTIONS/RESPONSIBILITIES:
- Review and manipulate data and reports from multiple sources
- Design and maintain databases, data reports, and dashboards for tracking and reporting of quality.
- Develop functional and technical specifications for data extracts to be used for data analysis and reporting
- Collaborate closely with SQL Programmers to interpret, define, and document data extraction specifications
- Develop easy-to-understand charts, tables, and graph for diverse audiences.
- Monitor and quickly address audits and data issues as they arise; escalate issues and support resolution in collaboration with the Manager of Quality Assurance.
- Incorporate quality improvement methods via all data dashboards and presentations
- Collaborate with other departments in order to interpret and assess needs of data requests.
- Ensure the quality and timeliness of assigned deliverables; manage multiple concurrent projects.
- Detail oriented with an understanding of quality improvement processes and related data skills
- Participate in the development and implementation of efficient and effective QA methodology including test automation, processes, procedures, templates guidelines and tools.
- Determine root cause for data quality and make recommendations for long-term solutions.
- Develop and maintain quality assurance process and procedure documentation and job aids to ensure consistent findings and determinations
QUALIFICATIONS:
EDUCATION :
- High School Diploma or GED required
EDUCATION PREFERRED/DESIRABLE:
- Bachelor degree or higher
- Experience with CMS Auditing, Star Ratings and CAHPS surveys
- Experience with data reporting and analytics
- SQL
EXPERIENCE:
- 5+ years in an HMO or other managed care setting, with experience on Medicare products such as a Medicare Advantage Plan, SCO or Duals Plan a plus
- Working knowledge of Healthcare Operations and Claims and Enrollment processing
- Call center or customer service quality monitoring knowledge and quality improvement concepts, practices and procedures
EXPERIENCE PREFERRED/DESIRABLE:
- Project management
- Prior experience within an HMO, PPO or other health plan
- Prior experience within a Medicare Advantage, FFS, or other, organization and/or a Medicaid managed care organization
- Prior experience evaluating and managing vendor quality
- Experience with CMS Stars Ratings and CAHPS surveys
- Experience with data reporting and analytics
CERTIFICATION OR CONDITIONS OF EMPLOYMENT:
- Quality Certification preferred (CPHQ, CQE, CQA, etc.)
COMPETENCIES, SKILLS, AND ATTRIBUTES:
- Knowledge of Medicare regulations
- Effective collaborative and proven process improvement skills
- Strong oral and written communication skills; ability to interact within all levels of the organization.
- A strong working knowledge of Microsoft Office products
- Demonstrated ability to successfully plan, organize and manage projects
- Demonstrates strong organization skills and ability to work in a rapidly changing environment
- Familiarity with government programs such as Medicare and/or Medicaid
- Claims or other experience using industry standard coding
- Experience applying analytical results to decision-making
- Excellent team player with strong leadership skills
- Must be able to effectively manage activities across multiple departments
- Requires the capacity to clearly communicate complex issues and problems and escalate effectively
- Detail oriented, excellent writing, proof reading and editing skills required
- Ability to build and lead effective teams
- Ability to work independently and collaboratively, manage multiple projects and meet scheduled deadlines
*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.
Required Skills
Required Experience