Employment Spot

Job Description

The purpose of this position is to establish a planned, systematic approach of quality assurance to identify key functional and regulatory weaknesses within the operational department, and provide recommendations for efficient and sustainable solutions for the affected areas. Develops, organizes, administers, evaluates and coordinates a comprehensive quality assurance program to ensure operational efficiency and compliance with State and Federal regulatory requirements. This position is responsible for all activities involving quality assurance and compliance with applicable regulatory requirements, and conducting audits and reviewing/analyzing data and documentation. This position relies on extensive experience and judgment to plan and accomplish goals, and performs a variety of tasks and ad hoc audits/reports. This incumbent may lead and direct the work of others, and a wide degree of creativity and latitude is expected.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

• Performs quarterly audits of enrollment, disenrollment and billing operations.

• Provides statistical analysis based on audit results for dissemination to management for use in identifying knowledge deficits and productivity issues.

• Identifies functional area deficiencies.

• Prepares, reviews, updates and monitors Standard Operating Procedures, with input from Subject Matter Experts (SMEs), to ensure proper process documentation, as well as compliance with CMS regulations.

• Reviews departmental policies and procedures to ensure compliance with functional and operational guidelines.

• Provides support for internal and external regulatory audits, reviews and site visits.

• Identifies potential compliance risks and recommends opportunities for improvement.

• Participate in internal committees to provide QA support.

• Participates in the development and facilitation of various quality assurance training with emphasis on work procedures and techniques to appropriate staff.

• Supports implementation and maintenance of the Corporate Compliance Program.

• Serves as technical expert on quality assurance related matters advising management on principles and techniques of quality assurance.

• Develops and conducts various quality assurance training with emphasis on work procedures and techniques appropriate to the work environment.

• Assists with setting milestones for accomplishing unit goals.

• Researches and implements latest developments in quality assurance by review of technical publications and documented independent studies.

• Perform other tasks as assigned.

• Must be willing to travel.

• Reviews and familiarizes self with Medicare operating materials, memorandums, and guidance to ensure regulatory compliance.

Job Requirements

• Knowledge of quality assurance principles, practices and procedures and ability to apply this knowledge to the planning and accomplishment of a variety of work assignments.

• Knowledge of and skill in applying various methods and techniques for investigating, analyzing and effecting corrective action on complex quality problems.

• Thorough and detailed knowledge of and skill in applying various methods and techniques for investigating, analyzing and effecting corrective action on complex quality problems.

• Ability to apply sampling methods.

• Ability to research, analyze, interpret and apply rules, regulations, and procedures.

• Ability to interpret Federal and State laws and regulations.

• Ability to gather, analyze and present facts.

• Ability to give oral presentations.

• Ability to plan and organize work; strong interpersonal skills.

• Strong written and oral communication skills.

• Working knowledge of Microsoft Office systems including Word, Excel, and Access. Knowledge of Visio, Project and Facets a plus.

LANGUAGE SKILLS

• Ability to read and comprehend documents including CMS/Medicare guidance, operating instructions and procedure manuals.

• Ability to compose and write effective correspondence.

• Ability to communicate effectively with colleagues within the department, as well as other areas within the Company.

EDUCATION and/or EXPERIENCE

• Bachelor's degree preferred; 5-8 years of direct experience in the field required.

• Previous experience in a health insurance/medical background in the quality assurance/control environment.