Job Title: Quality Data Analyst/Auditor- Hansen
Requisition Number: 17-612
Area of Interest: Green Bay,WI
Job Description and Essential Functions
Job Title/Position: Quality Analyst/Auditor
Job Classification: Administrative/Professional Support
Date of Analysis: Date of Revision/Review:
Brief Description of Job Responsibilities:
Manage quality aspects of insurance contracts to assure that Prevea Health receives negotiated reimbursements for meeting required quality metrics. Review medical records to gather information and work with providers to assure that documentation of quality metrics meet established standards.
(This list may not include all of the duties assigned)
- Review awarded insurance contracts, renewals and amendments for accuracy and compliance with agreed upon terms.
- Communicate contract terms, payment structures and reimbursement opportunities to others as needed
- Assist with implementation of new contracts and programs to ensure contract requirements are met with regard to quality metrics.
- Assist in developing workflows to capture quality metrics tied to reimbursements available through insurance contracts.
- Review medical records and extract relevant data to meet quality metrics and/or audit metrics for accuracy.
- Review reports and data provided by insurance payors for accuracy and perform medical record reviews to verify.
- Prepare audit reports and streamlines workflows in an effort to meet monthly, quarterly and annual goals.
- Monitor contract performance to identify gaps in meeting contract requirements and suggest corrective action to resolve operational issues as needed.
- Track and forecast revenue associated with meeting quality metrics defined in insurance contracts.
- Publish reports that demonstrate success or opportunity with meeting required measures.
- Consider opportunities for automation of pulling quality data through EPIC, Phytel or other data sources
- Work with EPIC optimization specialist, Clinical Applications Coordinator, Medical Director of Quality and Providers to develop and implement best practices to improve workflows related to meeting quality metrics associated with insurance contracts.
- Communicate regularly with Medical Director of Quality and Chief Financial Officer to prepare information necessary for contract renewals and amendments.
- Review, assist and suggest improvements in negotiating all insurance contracts including renewals.
- Develop educational materials for Providers and staff as needed.
- Assist with other quality initiatives as needed.
- Bachelors Degree in health related field preferred.
- Clinical experience as MA or LPN preferred.
- Familiarity with Quality measures such as HEDIS preferred.
- Familiarity with Medical Record documentation and coding guidelines preferred.
- Familiarity with medical insurance claims process preferred.
- Experience with electronic medical records, EPIC preferred.
- Knowledge of insurance contracts preferred.
- The nature of the work is repetitive and detailed. Keen attention to detail, strong focus and organizational skills are essential for proficient accuracy and efficient output and to meet scheduled timeframes and goals.
- Must have the ability to prioritize to meet deadlines.
- Self starter with the ability to work independently to achieve company goals.
- Experience performing data analysis and demonstrated ability to present data utilizing a variety of formats.
Typical Working Conditions:
Exposure to communicable diseases, toxic substances, ionizing radiation, medicinal preparations and other conditions common to a healthcare facility.
Typical Physical Demands: Requires full range of body motion including handling and lifting patients, manual and finger dexterity and hand-eye coordination. Requires standing and walking for extended periods of time. Occasionally lifts and carries items weighing up to 100 pounds. Requires corrected vision and hearing to normal range. Requires working under stressful conditions or working irregular hours. Requires exposure to communicable diseases and bodily fluids
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
How to Apply:
We have over 1200 reasons for you to consider a career with Prevea Health--they're our employees. We're an organization that values teamwork and provides continuous education, training and support so every member of the team contributes to our success. We offer a competitive salary and benefits package in an environment geared to professional and personal growth. No matter what your background or professional interests are, we think you'll like what we have to offer. Together we are the best place to get care and the best place to give care.
Prevea Health is an Equal Employment Opportunity/Affirmative Action employer.