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