Quality Assurance Analyst - Healthcare

Quality Assurance Analyst - Healthcare

 

Connolly Consulting is a healthcare industry leader specializing in providing financial auditing, consulting and overpayment identification services to commercial insurers across the country. We are a growing and profitable recovery audit firm that serves clients in the healthcare, retail, and commercial industries.

 

The Quality Assurance Analyst is a position within the Connolly Healthcare audit engagement reporting to the Director of Client Relations/Quality Assurance.

 

Responsibilities will include but is not limited to:

 Execute a quality assurance audit program within defined targets with  proficient knowledge of Medicare reimbursement/ payment policies/practices.Have direct focus on continuous quality improvement initiatives (CQI).Supporting the process of validating work flows and communication tools to best enhance audit production, client satisfaction, and quality assurance. Analyze and validate audit finding to all internal clients. Audit, mentor and support; suggest improvements and recommendations to meet the highest level of client satisfaction. 

 

Accountabilities:

 Document and report quality related concerns to management.Promote audit accuracy measure by mentoring the auditor and providing documented and validated findings.  Recommend quality initiatives to promote audit accuracy measures based on the auditing of inter-rater reliability studies, rebuttals, appeals, overturns, telephone inquiries, and assess customer/provider/stakeholder issues, complaints and compliments. Participate in both pre-release and post-release audit reviews. Utilize audit reviews and reports to identify performance issues with a focus on continuous quality improvement.  Responsible for identifying, documenting, and recommending training of processes or techniques to meet accuracy requirements. Respond timely and accurately to inquiries with findings based upon defensible and documented rationale.  Participate in weekly/monthly QA meetings to share best practices initiatives and recommend audit vulnerabilities.  Support the Contractor Medical Director to ensure accurate assessments of improper payments are based on consistent application of Medicare guidelines.Wwork with IT support staff to develop and implement auditing tools.

Qualifications

The specific minimum competencies required for job performance are as follows:

·         BA/BS required. Degree(s) in Nursing, Healthcare Economics, Health Information Management and/or Business (Accounting/ Finance) preferred.

·        7+ years in any of the following: claims auditing/quality assurance/recovery auditing/customer and/or client support experience – ideally in a Medicare and/or hospital environment.

·         Knowledgeable in Medicare reimbursement/payment policies, audit reviews and analysis, medical terminology and/or CERT report analysis.

 

·         In depth knowledge of ICD 9, DRG, CPT Coding, HCPCS, Revenue Codes, Coding Clinic, and medical terminology. Additionally, CMS CLAIMS Manual, OIG Work Plans. Able to synthesize the information, concisely communicate either verbally or in writing findings and recommendations.

 

·        Subject matter expertise in Medicare reimbursement/payment policies, audit reviews and analysis, medical terminology and/or CERT report analysis. Additionally, CMS CLAIMS Manual, OIG Work Plans. Able to synthesize the information, concisely communicate either verbally or in writing findings and recommendations.

 

·         Current, valid inpatient coding certification a plus.

 

·         Ability to apply (InterQual and/or Milliman) practice management guidelines to determine medical necessity, and appropriateness of coding and billing.

 

·         Strong presentation skills. Comfortable in presenting/defending audit logic to client and key stakeholders (i.e. hospitals, physicians, validation contractors, auditing team,).

 

·         Independent thinker, logical, strategic, with a high focus and attention to detail.

 

·         Effective communication and presentation style (written and verbal) with proven ability to positively influence behavior and outcomes.

 

·         Competent administrative and organizational skills, ability to multitask, set priorities, and meet deadlines.

 

·         Professional demeanor:  Ability to creatively solve problems, deal with ambiguity, develop and implement policy and procedures, perform analysis and prepare reports, and foster team building.

 

·        Proficient computer skills: Comfortable with systems and proficient in Access, Excel, Power Point, Microsoft Project and other applications.

 

·         Travel requirement 15-30%

 

Familiarity Success factors

 

Personal characteristics that contribute to an individual's ability to excel on the job: Connolly Consulting’s Non-Negotiable Traits: Customer Service Focused Integrity Self-Motivated Passionate Team Player Results Oriented Reliable Professional Boundaryless Behavior

Connolly Consulting's most important resource is experienced, committed, and creative employees. The open and inclusive team-oriented culture encourages contribution and enables employees to go beyond to fulfill his or her potential. Connolly is unique in its uncompromising commitment to provide the highest level of quality in auditing services. Connolly offers careers with plenty of challenge and opportunity, in a rewarding atmosphere. If you have a proven track record of accomplishment, commitment, and passion for success than Connolly is the right choice for you.