UM Quality Representative

OncoHealth; United States; Hybride; USD 52 000 - 72 000; Plein temps

Résumé du poste

OncoHealth is seeking a UM Quality Representative to ensure that UM case processing and customer support meet the highest standards for our clients, patients, and payers. You will perform audits, identify gaps, and support training in a fast-paced environment with remote/hybrid work options.

Responsibilities include data analysis, documenting findings, and ensuring timely handling of complaints and payer audits in line with company turnaround times.

Qualifications

• Bachelor's Degree or relevant experience preferred.
• At least 2 years of experience in a payer, provider, or healthcare vendor setting with patient data responsibility.
• Demonstrates attention to detail, critical thinking, and decision-making abilities.
• Maintains confidentiality and communicates professionally with employees and outside entities.

Responsabilités

• Complete quality audits/validations according to internal processes and regulations for pre-authorizations, phone calls, and other UM and customer support processes.
• Identify/document process gaps and communicate audit observations, recommendations, and improvement opportunities.
• Monitor, evaluate, and report on the progress of newly hired UM and Customer Support employees during training.
• Assist in developing and implementing quality standards/processes.
• Follow up with managers when mistakes are found and collect data to identify opportunities for UM operations improvement.
• Support UM Operations Teams with payer audit requests and gather documentation for audits.
• Offer training and support to representatives in identified areas needing improvement.
• Provide training to new hires covering systems, policies, procedures, and core processes.
• Ensure client complaints are captured, researched, and resolved within OH’s turnaround times.
• Register and regularly review complaints to identify patterns and opportunities for improvement.

Connaissances

Detail orientation

Critical thinking

Decision making

Advanced customer service

Interpersonal skills

Active listening

Time management

Multitasking

Documentation

Formation

Bachelor's degree or relevant experience

Description du poste

OncoHealth is a leading digital health company dedicated to helping health plans, employers, providers, and patients navigate the physical, mental, and financial complexities of cancer through technology enabled services. Supporting more than 14 million people in the US and Puerto Rico, OncoHealth offers digital solutions for treatment review and virtual care across all cancer types.

About the Role

The UM Quality Representative is responsible for ensuring that services for UM case processing and customer support meet the established standards set by the company to ensure the highest quality is delivered to our clients.

Primary Responsibilities

• Flexible to work rotational shifts inside our office hours from 8:00 a.m. – 8:00 p.m. EST to cover the operational needs of the company. Shifts can range anywhere between Monday – Friday 8:00 am to 8:00 pm EST and Saturdays 8:30 am - 5:00 pm EST (Office hours may change/extend upon operational needs).
• Complete quality audits/validations according to the established internal process, policies, National and/or State regulations and guidelines for pre-authorizations, phone calls, and other UM and customer support processes
• Identify/document any process gaps and deficiencies and communicate audit observations, recommendations, and process improvement opportunities resulting from quality audits
• Monitor, evaluate, and report on the progress of newly hired UM and Customer Support employees during the initial training period through audits
• Assist in developing and implementing quality standards/processes
• Follow up with the appropriate managers and staff when mistakes are found
• Collect and analyze data to identify opportunities for improvement in UM operations
• Support UM Operations Teams with Payer audit requests that require verification of the quality/ accuracy of case information and gather any supportive documentation needed for completion of the audit
• Offer training and support to representatives in the areas identified as needing improvement from the audit results
• Provide training and support to new hires of the Quality Support team that covers systems, policies, procedures, and core processes
• Ensure client complaints are captured, researched by the responsible department, and communication of resolution are executed in accordance with OH’s complaint handling turnaround times
• The registration of all complaints and components.
• Regularly review complaints to check for patterns in the type, nature, and handling of complaints to identify any improvement opportunities
• Contact provider and request medical records as required
• Process protocols according to payer’s process and contract TAT’s

About You

• Bachelor’s Degree or relevant experience preferred
• At least 2 years of experience working in a payer, provider, or healthcare vendor setting with patient data responsibility, or relevant experience required.
• Demonstrates detail-orientation, critical thinking, and decision-making abilities required.
• Must be able to relate in a respectful, professional, courteous manner with employees and outside entities.
• Maintains strict confidentiality of sensitive information and utilizes established communication channels to ensure accurate, secure, and professional information sharing.
• Ability to prioritize and organize multi-faceted/multiple responsibilities, time manage and prioritize in a fast paced, changing environment while meeting deadlines and turnaround time requirements.
• Advanced customer service skills, excellent interpersonal and active listening skills, ability to work well in a team.
• Must also have multi-tasking, quality focus, problem-solving, and documentation skills.
• Must be able to work independently utilizing all resources available while staying within the boundaries of duties.

About the Location

OncoHealth is committed to remote, hybrid or in office work options. The majority of the team will be remote or in hybrid work arrangements with offices in Atlanta, GA and Guaynabo, PR. We are open to employees nationwide but work primarily in the Eastern and Central Time Zones.

Our Culture

Taking ownershipof quick action, critically thinking through the needs, and working well with others are key competencies ofteam member success. Our leadership is dedicatedtobuilding a culture based onrespect, clinical excellence, innovation– allwithafocused mission of putting patients first!

We offer a full benefit package on your first day, along with a company bonus. You may visit or work from our very modern and engaging offices, and experience a fun, collaborative environment where social activities and community events matter. We enjoy being together!

OncoHealth is committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and team members without regard to race, color, religion, marital status, age, national origin, ancestry, physical or mental disability, medical condition, pregnancy, genetic information, gender, sexual orientation, gender identity or expression, veteran status, or any other status protected under federal, state, or local law. All employment decisions are based on qualifications, merit, and business need.

The Opportunity

The cost of cancer related medical services and prescription drugs in the United States is expected to reach $246billionby 2030.OncoHealth has enjoyed rapid growth over the past 3 years and seeks smart, collaborative people to join its team. We have just under 250 team members, so we can move swiftly but precisely to the market needs of our customers. Strongly backed financially by Arsenal Capital Partners & McKesson Corporation, we remain in an investment and growth mode. This means we are open-minded to how we get the work done – now is the perfect time to talk to us!

Our Current Solutions

Through the use ofOncoHealth's utilization management system, OneUM, our customers can use a single e-Prior Authorization portal for all oncology drug request and treatments. Our system improves quality of care, reduces provider abrasion and gives health plans visibility into the total cost of oncology treatment.

OncoHealth offers Oncology Insights Pro, ananalytic software solution that enableshealth plansto use data and analytics to improve oncology programs. Using real world data, our engineers normalize data to create analytic dashboards with drill down compatibilities. The data is the paired with expert guidance providing the strategies an insight needed to keep up with the continuing evolving cancer treatment landscape.

OncoHealth offers Pharmacy Consultingservices to health plans and pharmaceutical companies. New cancer treatments are entering the market at an unrelenting pace. Since 2018, the FDA approved 121 new cancer applications including 49 novel cancer drug entities. Our Board-Certified Oncology Pharmacologists can help health plans update drug policies, offer utilization management and formulary advice, and development training for staff.

OncoHealth's latest offering is Iris, a digital telehealth platform that delivers personalized, oncology-specific support to navigate the physical symptoms and emotional challenges caused by cancer and cancer treatment. Powered by technology, staffed 24X7, and delivered with empathy, Iris allows patients to connect with trained oncology experts and receive personalized, oncology-specific telehealth support.