Quality Analyst/Auditor- Green Bay, WI - Full Time

PREVEA HEALTH; Green Bay (WI); On-site; USD 65,000 - 85,000; Full time

Job summary

Prevea Health in Green Bay, WI is hiring a Quality Analyst/Auditor to manage quality measures across insurance contracts. You will review medical records, extract data, and ensure documentation aligns with contract requirements to optimize reimbursements.

Collaborating with clinicians and leadership, you will develop educational materials, support contract reviews, and push for workflow improvements. Prioritizing accuracy and compliance, you will help meet monthly and annual quality goals.

Qualifications

• Familiarity with quality measures such as HEDIS.
• Understanding of medical record documentation and coding guidelines.
• Knowledge of medical insurance claims processes.
• Familiarity with insurance contracts.
• Strong analytical, auditing, and organizational skills.
• Ability to communicate effectively with providers, leadership, and cross-functional teams.

Responsibilities

• Review medical records and extract data to meet quality and audit metrics; verify accuracy of documentation and coding.
• Assist with implementation of new contracts and programs, ensuring workflows meet contract requirements related to quality metrics.
• Develop educational materials and guidance to providers and staff on quality metrics and contract requirements.
• Support contract reviews by analyzing quality-related terms and interpreting performance thresholds to meet goals.
• Prepare audit reports and streamline workflows to meet monthly, quarterly, and annual quality goals.
• Monitor contract performance to identify gaps and recommend corrective actions.

Skills

HEDIS familiarity

Medical coding knowledge

Insurance claims know-how

Insurance contracts familiarity

Analytical skills

Communication skills

Education

Associate's degree healthcare admin or related

Tools

EPIC

Microsoft Office

Job description

Quality Analyst/Auditor- Green Bay, WI - Full Time

#26-533

Green Bay, Wisconsin, United States

Location

Hansen-006

Description

Quality Analyst/Auditor

Come work where we specialize in you! We have nearly 2,000 reasons for you to consider a career with Prevea Health—they're our employees. We're an organization that values kindness, responsibility, inclusivity, wellness and inspiration. At Prevea, we provide continuous education, training and support so every member of the team contributes to our success. Together we are the best place to get care and the best place to give care.

Job SummaryThe Quality Analyst/Auditor manages quality-related aspects of insurance contracts to ensure Prevea Health receives negotiated reimbursements for meeting required quality metrics. This position reviews medical records, analyzes payer data, and collaborates with providers and leadership to ensure accurate documentation, compliance, and optimization of quality performance tied to insurance contracts.

What you will do

• Review medical records and extract relevant data to meet quality and audit metrics; verify accuracy of documentation and coding. Review reports and data provided by insurance payors; perform audits and medical record validation to ensure accuracy.
• Assist with implementation of new contracts and programs, ensuring workflows and processes meet contract requirements related to quality metrics.
• Develop educational materials and provide guidance to providers and staff related to quality metrics, documentation standards, and contract requirements.
• Support contract review by analyzing quality-related terms within assigned insurance contracts and amendments; interpret and communicate quality measure requirements and performance thresholds to support achievement of contract goals
• Prepare audit reports and streamline workflows to meet monthly, quarterly, and annual quality and performance goals.
• Monitor assigned contract performance to identify gaps in meeting quality requirements; recommend and support corrective actions as needed.
• Identify and support opportunities for automation of quality data extraction using EPIC or other data sources.
• Collaborate with Clinical Optimization Team, Chief Quality Officer, Chief Financial Officer, and Physicians/Clinicians to develop and implement best practices for quality-related workflows.

Education Qualifications

• Associate's Degree Healthcare Administration or Technical Diploma in Healthcare related field Preferred

Experience Qualifications

• 2+ years Healthcare related work experience Required
• Clinical experience as MA or LPN Preferred
• Experience with electronic medical records, EPIC, and Microsoft Office Preferred

Skills and Abilities

• Familiarity with quality measures such as HEDIS.
• Understanding of medical record documentation and coding guidelines.
• Knowledge of medical insurance claims processes.
• Familiarity with insurance contracts.
• Strong analytical, auditing, and organizational skills.
• Ability to communicate effectively with providers, leadership, and cross-functional teams.

Physical Demands

• Sit - Constantly
• Stand - Rarely
• Walk - Rarely
• Drive - Rarely
• Bend (Neck) - Constantly
• Gross Manipulation (Hands/Arms) - Occasionally
• Twist/Turn (Neck) - Frequently
• Twist/Turn(Waist) - Occasionally
• Lift/Carry 0-10 lbs. - Occasionally
• Lift/Carry 11-25 lbs. - Rarely
• Lift/Carry 26-35 lbs. - Rarely
• Push/Pull up to 10 lbs. - Rarely
• Push/Pull 11-25 lbs. - Rarely
• Push/Pull 26-35 lbs. - Rarely
• Reach (Above shoulder level) - Rarely
• Reach (Below shoulder level) - Frequently
• Simple Grasping (Hands/Arms) - Frequently
• Fine Manipulation (Hands/Arms) - Frequently
• Gross Manipulation (Hands/Arms) - Occasionally

Working Conditions

• Noise - Occasionally

Travel Requirements

• 5%

Hearing Requirements

• Hears Whispers < 3 feet - Constantly
• Hears Whispers 3-8 feet - Constantly

Vision Requirements

• Color Discrimination - Constantly
• Near Vision (Correctable to Jaeger 2 or 20/40 binocular) - Constantly
• Distance Vision (Correctable to Snellen chart 20/40 binocular) - Constantly

Prevea is an Equal Employment Opportunity/Affirmative Action employer. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United State and to complete the required employment eligibility document form upon hire. Prevea participates in E-verify. To learn more about E-Verify, including your rights and responsibilities, please visit www.dhs.gov/E-Verify

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E-Verify

Incompliance with federal law, all persons hired will be required to verifyidentity and eligibility to work in the United State and to complete therequired employment eligibility document form upon hire. Prevea participates inE-Verify. To learn more about E-Verify, including your rights andresponsibilities, please visit www.dhs.gov/E-Verify

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