Quality Control Analyst

Job Duties and Responsibilities Prioritize incoming authorization and referral requests according to queue urgency Review patient’s clinical and chart documentation related to the service submitted by the provider’s office Obtain and/or follow up on authorization and referral requests from the patient’s payer/s through any of the following methods—depending on the payer’s policy: Perform outbound calls to payer’s authorization department Access payer’s authorization online portal Submit faxes to payer’s authorization department Respond to payer’s clinical questions to be able to proceed with the authorization and referral requests Obtain and/or follow up payer’s peer-to-peer review requirements and send them back to provider’s office for the actual initiation Cater inbound calls from payers and perform necessary actions required for the task Listen and review voicemail messages from payers then perform necessary actions required for the task Monitor activities of Nurses to assess schedule adherence, accuracy, quality, productivity, timeliness and compliance with job requirements, policies and procedures. Report updates to management. Provide basic on-the-job training for direct reports and serve as a resource to address questions related to the policies, processes and procedures. Delivers required number of QA Monitors on a timely manner Provide quality metric analysis on compliance scores Participates in call calibration to understand and identify targets Generates and trends daily/weekly/monthly QA related reports Performs side-by-side sessions and provide real-time feedback Skilled in pinpointing root cause/s for performance variance Provide recommended intervention activities to address quality metric opportunities identified Required Skills Solid understanding of anatomy & physiology, including how body systems function and an understanding of disease processes Comprehensive understanding of Medical Terminology Prior experience in processing multispecialty authorizations including contact with payers Experience in prior authorization process Experience with general computer software (Internet, Word, Outlook, PDF required) Proficiency to learn new software programs quickly Excellent customer service skills: communicates clearly and effectively Excellent verbal and written communication skills Professional and effective interaction skills with co-workers, clients, providers, and vendors Proven ability to work well individually and as a team member Strong attention to detail Ability to follow company and account-specific standard operating procedures and policies Ability to adapt to constantly changing environment Ability to prioritize and organize multiple tasks by remaining focused and quality-driven at all tasks at hand Ability to remain organized with multiple interruptions Ability to make decisions independently without bypassing any company and account-specific standard operating procedures and policies Ability to comfortably receive constructive feedback Required Experience Graduate of Bachelor of Science in Nursing with active PH registered nurse license 1 year of experience of US healthcare authorization business At least 2 years of experience in the BPO/Healthcare industry is an advantage Bachelor's Degree in Nursing with active PH Registered Nurse license Minimum 2 years of Quality Analyst experience in a US Healthcare account (Prior Authorization or Claims/Denial/Appeal) Excellent Leadership & Interpersonal relationship Strong Process Management & planning skills Embrace change and think operationally to achieve business goals Proven process improvement experience Seniority level Mid-Senior level Employment type Full-time Job function Quality Assurance Industries Hospitals and Health Care and Outsourcing and Offshoring Consulting #J-18808-Ljbffr