Quality Analyst - Authorization

Med-Metrix; Manila; On-site; PHP 600,000 - 900,000; Full time

Job summary

Med-Metrix is seeking a Quality Analyst to support quality auditing, analysis, reporting and the development of improvement plans in a healthcare setting. The role emphasizes HIPAA compliance, risk analysis, and collaboration with Operations and Training teams.

The candidate should have at least 2 years of QA experience in healthcare insurance collections or customer service, with strong communication and problem-solving skills to drive performance improvements and ensure adherence to policies.

Qualifications

• At least 2 years previous work experience as a Quality Analyst in healthcare insurance collections, self-pay collections and customer service in a call center setting or compliance and/or training
• Experience with training new users
• Knowledge of EOBs, CPT & ICD-9 & 10 codes, HCFAs, UB92s, HCPCS, DRGs and authorizations/referrals
• Strong understanding of the basic healthcare revenue cycle operational processes such as the functions of insurance, patient billing & collections, Managed Care, Medicare, Medicaid, and Commercial Practices
• Knowledge of the denied claims and appeals process
• Must have an experience in outbound transaction AR process (Payers)
• Proficient computer skills including Microsoft Office Suite, intermediate Excel skills required
• Strong interpersonal skills, ability to communicate well at all levels of the organization
• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses

Responsibilities

• Ensure project related quality processes are followed by denials analyst and client specific and internal metrics are achieved
• Prepare detailed reports on audit findings and understand the quality requirements both from process perspective and for targets. Deliver reports in a timely manner.
• Identify a method to achieve the quality targets and implement the same in consultation with QCA lead and/or managers.
• Assist with the Quality Assessment process to ensure all quality standards targets can be met.
• Participate in performance improvement activities and continuing education to maintain current credentials and enhance knowledge and skills
• Share all relevant information with the team and take initiative to ensure team members get projects completed
• Participate in client presentation of findings, when requested
• Adjust workloads as necessary to achieve successful completion of project
• Handle complaints, questions, and queries as necessary
• Disseminates changes in guidelines and rules; monitor changes in laws, regulations, and policies that impact clinical documentation, reimbursement to assure compliance
• Foster an environment of teamwork and service excellence within the department
• Participate in conference calls/meetings with management and staff to ensure all performance and training recommendations are addressed and improvement suggestions are implemented
• Assist in new hire training classes, transition periods and refresher trainings as needed
• Maintain knowledge, understanding of, and compliance with all Med-Metrix policies and procedures.
• Participate in presentations to educate staff on outcomes and plans of correction
• Other duties as assigned
• Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Understand and comply with Information Security and HIPAA policies and procedures at all times
• Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties

Tools

EPIC PB

Allscripts

Cerner

Job description

Job Purpose

The Quality Analyst supports quality auditing, analysis, reporting and the development of plans that lead to positive outcomes. The Quality Analyst will work on risk identification, diagnosing issues, identifying process improvement solutions and process improvement implementation methods utilizing sound principles. Continuous engagement and collaboration with the Operations and Training Team is essential.

Duties & Responsibilities

• Ensure that project related quality processes are followed by denials analyst and client specific and internal metrics are achieved
• Prepare detailed reports on audit findings and understand the quality requirements both from process perspective and for targets. Deliver reports in a timely manner.
• Identify a method to achieve the quality targets and implement the same in consultation with QCA lead and/or managers. Assist with the Quality Assessment process to ensure all quality standards targets can be met.
• Participate in performance improvement activities and continuing education to maintain current credentials and enhance knowledge and skills
• Share all relevant information with the team and take initiative to ensure team members get projects completed
• Participate in client presentation of findings, when requested
• Adjust workloads as necessary to achieve successful completion of project
• Handle complaints, questions, and queries as necessary
• Disseminates changes in guidelines and rules; monitor changes in laws, regulations, and policies that impact clinical documentation, reimbursement to assure compliance
• Foster an environment of teamwork and service excellence within the department
• Participate in conference calls/meetings with management and staff to ensure all performance and training recommendations are addressed and improvement suggestions are implemented
• Assist in new hire training classes, transition periods and refresher trainings as needed
• Maintain knowledge, understanding of, and compliance with all Med-Metrix policies and procedures.
• Participate in presentations to educate staff on outcomes and plans of correction
• Other duties as assigned
• Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Understand and comply with Information Security and HIPAA policies and procedures at all times
• Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties

Qualifications

• At least 2 years previous work experience as a Quality Analyst in healthcare insurance collections, self-pay collections and customer service in a call center setting or compliance and/or training
• Experience with training new users
• Knowledge of EOBs, CPT & ICD-9 & 10 codes, HCFAs, UB92s, HCPCS, DRGs and authorizations/ referrals.
• Strong understanding of the basic healthcare revenue cycle operational processes such as the functions of insurance, patient billing & collections, Managed Care, Medicare, Medicaid, and Commercial Practices
• Experience with practice management systems. EPIC PB, Allscripts and/or Cerner preferred
• Knowledge of the denied claims and appeals process
• Must have an experience in outbound transaction AR process (Payers)
• Ability to navigate through multiple software and computer applications
• Capacity to maintain a high level of objectivity when completing staff reviews
• Proficient computer skills including Microsoft Office Suite, intermediate Excel skills required
• Self-motivated and resourceful with the ability to multitask and successfully operate in a fast paced, team environment
• Strong interpersonal skills, ability to communicate well at all levels of the organization
• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
• High level of integrity and dependability with a strong sense of urgency and results oriented
• Ability to meet assigned deadlines and work under minimal supervision and with all levels of staff and management.
• Excellent written and verbal communication skills required

Working Conditions

• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress
• Work Environment: The noise level in the work environment is usually minimal

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.