Quality Assurance Specialist

This position is a member of the Quality and Compliance team to ensure adherence to regulatory requirements company policy and protocols and achievement of quality standards. Responsible forconducting audits of medical records coding utilization and billing patterns to ensure the services performed and clinical information within the medical record is accurate appropriate complete and compliant. Reports to the Senior Director of Corporate Operations Quality Assurance and Compliance.

Education: High school diploma or equivalent required. Bachelors degree in Healthcare Administration Business Administration Organizational leadership or related field preferred.

Experience:3 years of experience in healthcare quality assurance utilization management risk management compliance or related experience. Experience in behavioral health is a plus.

Licenses/Certifications: Fellowship of the American College of Healthcare Executives(FACHE) Certified Healthcare Financial Professional (CHFP)Certified Professional in Healthcare Risk Management (CPHRM) or related certication is preferred

Responsibilities:

Utilization Reviews

• Analyzing patient records to assess the need for and appropriateness of medical treatments.
• Checking if treatment plans adhere to Deer Oaks utilization review guidelines and insurance policies.

• Reporting Analyzing and Evaluating Data:
• Proactively review clinical data and other relevant clinical and billing data to identify trends patterns repeat outliers re-education needs potential compliance/clinical practice concerns policy gaps/update needs and areas for improvement.
• Generate monthly QA reports for management.
• Analyze data related to quality and compliance metrics and prepare reports to track progress and identify areas for improvement.
• Generate reporting and complete data reviews as necessary for customer contracts or insurance plans.
• Conducting Audits and Reviews:
• Performing audits of healthcare practices and processes to identify areas needing improvements.
• Performing audits of providers triggered due to unusual patterns in claims data or during data analysis of risk areas.
• Performing audits that are triggered by compliance issues/investigations or external record reviews and audits from insurance companies and regulatory agencies.
• Serve as internal utilization reviewer for determination of continued care for patients on caseload for an outlying time period.
• QA monitoring to ensure compliance of Corporate Chain Contracts or Insurance Plans specific guidelines requirements expectations
• Assists with compiling medical records and clinical summaries for external record reviews and audits from insurance companies and regulatory agencies.
• Maintains tracking tools to log audits conducted findings and recommendations.
• Based on data analysis and documentation reviews identifies and clearly communicates (verbally and in written reports or summaries) potential quality of care and service issues for further action.
• Supports other Quality Improvement efforts as needed. Collaborates with the QA and Compliance Leadership Team to develop and implement programs for ongoing quality and clinical documentation improvements.
• Assists with creating and revising audit tools and quality reporting as necessary to ensure audits and reports are value added for senior and executive management.
• Participates in special projects collecting analyzing and summarizing data utilizing Excel and prepares professional reports to communicate findings and recommendations to QA and Compliance Leadership Team.
• Contributes creative solutions and ownership of daily assignments for seamless communication and systematic completion of routine and special projects.
• Other duties as assigned to support the companys mission.

Required Skills/Experience/Abilities:

• Solution-oriented dependable self-starter with solid ability to work in a team environment.
• Excellent communication skills. This includes written and verbal communication active listening and clear articulation.
• Analytical thinking with the ability to identify and resolve issues effectively evaluate arguments and make sound judgements.
• Keen attention to detail.
• Manages tasks information and resources efficiently.
• Builds and maintains positive relationships with others.
• Ability to collaborate effectively with colleagues to achieve shared goals.

• Performs multiple tasks independently with a fast-paced proactive vs. reactive approach to changing priorities.
• Demonstrates dependability diligence and a strong commitment to work.

• Advanced skills with Microsoft Office applications especially Excel. Must be able to complete data manipulation formulas pivot tables charts data validation and conditional formatting within Excel.
• Keen understanding of CMS HIPAA and other insurance and regulatory requirements governing healthcare providers.
• Thorough knowledge of medical coding ICD-10 CPT and HCPCS codes.

EEO Statement

It our policy to provide equal employment opportunity and treat all employees equally regardless of age race creed/religion color national origin immigration status or citizenship status sexual orientation military or veteran status sex/gender gender identity gender expression disability genetic information or genetic predisposition or carrier status marital status partnership status victim of domestic violence sexual or other reproductive health decisions or other characteristics protected by applicable law.

Required Experience:

Unclear Seniority