Responsible for evaluating the quality of services and interactions provided by organizations within the enterprise.
Primary duties may include, but are not limited to:
- Evaluates the quality and accuracy of transactions and/or communications with providers, groups, and/or policyholders.
- Identifies, documents, and reports any transaction errors or communications issues in a timely manner to ensure prompt resolution.
- Tracks and trends audit results, providing feedback to management.
- Conduct calibration sessions to evaluate and ensure that all teams are aligned with the set QA guidelines.
- Identifies and reports on systemic issues which create ongoing quality concerns.
- Conducts root cause analysis to determine the underlying causes of noted quality opportunities using the RCA tools.
- Recommend, implement, and monitor preventive and corrective actions to ensure that quality standards are achieved.
- Generates monthly reports of audit findings, supports clients with issues identified and develops reports to assist management with information requested.
- Produces other ad hoc reports as requested by internal and external clients.
- Associates at this level conduct routine to complex audits, generally related to one or more functions on one or more systems platform for one or more lines of business.
Requires a BS Nursing degree. At least 1 year bedside and/or utilizations management experience. At least 1 year QA experience. Working knowledge of healthcare industry and medical terminology, detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines; and ability to acquire and perform progressively more complex skills and tasks in a production environment required.
One or more of the ff certificates:
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Practitioner (CDIP)
- Certified Professional Coder (CPC)
- Inpatient Coding Credential such as CCS or CIC
