Quality Management Specialist

JOB SUMMARY Evaluate and enforce policies and procedures to maintain the quality of claims documented in Outcomes programs, collaborate with internal stakeholders to identify and outline quality standards as they relate to projects and processes that pose potential risk for quality related issues or fraud, waste and abuse (FWA). Analyze data, reports, operating practices, and documentation as part of the standard monthly claims close and internal auditing processes to ensure quality in business processes.ESSENTIAL DUTIES & RESPONSIBILITIESDemonstrate in-depth understanding of the business model, claim submission requirements and claim validation specificationsDevelop and manage an inventory of quality assurance system edits and coordinate with other departments to adjust, as neededIdentify and resolve MTM activity issues and complete fraud, waste, and abuse monitoring by analyzing data, reports, operating practices, and documentation as part of standard monthly claims close and internal auditing processes to ensure complianceDevelop and maintain network educational materials related to policies, procedures, and documentation requirements, including the policy and procedure guideCoordinate across departments to develop responses to client quality auditsStrategize, execute, and monitor corrective action plans for quality related incidentsReview daily data quality reports, identify inconsistencies and opportunities for improvementProvide quality assurance support across the business including reporting, processes and other areas as assignedKNOWLEDGE & REQUIREMENTSApplies working knowledge in the application of concepts, principles and technical capabilities to perform varied tasksWorks on projects of moderate scope and complexityIdentifies possible solutions to a variety of technical problems and takes action to resolveApplies judgment within defined parametersReceives general guidance and may receive more detailed instruction on new projectsWork reviewed for sound reasoning and accuracyHealthcare experience strongly preferredAbility to meet multiple deadlinesStrong written and verbal communication skillsAbility to communicate across all levels of an organization, demonstrating professionalism and good judgment at all timesMust be able to work autonomously (with minimal direction) while also being part of an integrated teamMust be able to manage competing demands and multiple priorities, while maintaining a strong attention to detailStrong quantitative, qualitative, and analytical skills including technical proficiency related to PC and basic office softwareEDUCATION & EXPERIENCE REQUIREMENTSMinimum years of work experience: 2 years IN healthcare is preferredMinimum level of education or education/experience: Bachelors or equivalent work experience in healthcare operations, preferably Medication Therapy Management or member patient communicationsPHYSICAL REQUIREMENTSThe physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this jobFrequent sitting in stationary position at a deskOccasional standing, walking, stooping, kneeling, squatting, and climbing stairsOccasional twisting of bodyOccasional reaching by extending hands and arms in any directionOccasional lifting, pulling, or pushingWhat's In It For You?Medical, Dental and Vision PlansVoluntary BenefitsHSA & FSAFertility and Family Planning BenefitsPaid Parental LeaveAdoption Assistance ProgramEmployee Resource GroupsFlex PTO for Exempt Associates and up to 15 PTO days in first year of employment for non exempt associates11 Paid HolidaysCorporate Wellness Program401(k) plan offering both pretax and Roth contributions, plus an employer match