JOB SUMMARY

Responsible for conducting audits to measure Quality Assurance across critical business processes. Complete analytical assessment of work product and processes to identify root cause of incidences and provide feedback to key stakeholders. Prepare reports to communicate QA results and findings to Leadership Team and process owners across the organization, driving accountability and ongoing improvement of QA metrics. Interface with internal customers to act as a functional and operational liaison for the end user group community. Understand policies and procedures and utilize them for daily Quality Assurance duties. Use The QA analyst will be responsible for documenting, and monitoring business processes and associated workflow.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Complete quality assurance inspections as required, ensuring standardization and compliance with established policies and procedures and applicable regulations.
Identify, research and document process improvement opportunities. Then collaborate with internal and external business partners (Operations, Compliance, Facilities, Payers) to drive accountability and process improvements.
Prepare and review data and QA reporting with key stakeholders.
Provide input for policies and procedures updates as required.
Special projects as assigned.

KNOWLEDGE, SKILLS AND ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The Ability to complete the review of a clinical appeal letter using critical thinking skills and practical application of national criteria guidelines, InterQual® (IQ) and Milliman® (MCG) evidenced based medicine.
The ability to evaluate the appeal letter when the national criteria guidelines are “not met”. This criterion includes co-morbid conditions, the patient age, and the medical predictability of an adverse outcome if the patient is not cared for in the appropriate level of care.
Must possess a clear knowledge of all clinical activity codes and their practical application to differing dispute scenarios.
The QA nurse analyst must have a clear understanding of the clinical dispute process, how to review a disputed account in ACE, the client specific Case Management application, the correspondence application, the EMR and any other associated applications such as N-thrive..
Must have a solid knowledge of patient’s across the lifespan from neonatal to geriatric age groups.
Possesses excellent written, verbal and professional letter writing skills
Ability to multi-task
Ability to conduct research regarding State/Federal appellate guidelines. LCD’s , NCD’s and payer policies and proceduresAbility to work independently to meet objectives in a repetitive auditing environment.
Possesses an exceptional eye for detail and process improvement.
Ability to identify problems, gather and analyze information skillfully and provide recommendations for process improvements.
Independent, logical thinker with ability to perform detailed data analysis
Demonstrated ability to build strong working relationships with key internal and external stakeholders (Centralized Operations, Compliance, Facilities) and be a thought leader/influencer for change.
Advanced troubleshooting abilities, with ability to problem solve complex technical issues
Must be capable of executing and publishing written requirements utilizing the business intent and goals, while providing technical details to support workflow or system development
Ability to develop and/or present training to operations trainers and/or business users
Intermediate level skills in applications such as Microsoft Excel, Word, and Visio
Additional skills preferred, not required:
Knowledge of healthcare revenue cycle
Knowledge/experience with system design in a database environment
Knowledge of project management methodologies
Knowledge of research methodology, principles and procedures

EDUCATION/EXPERIENCE

Must possess a valid nursing license (Registered or Practical/Vocational)
Minimum of 5 years recent medical surgical care experioence with the last 2 years in a facility environment
Medical-surgical/critical care experience
Minimum of 2 years UR/Case Management experience within the last 2 years
Managed care payer experience a plus either in Utilization Review, Case Management or Appeals
Patient Accounting experience a plus
Previous classroom led instruction on InterQual® products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred
Previous classroom led instruction on Milliman®, MCG preferred

CERTIFICATES, LICENSES, REGISTRATIONS

Current, valid RN, licensure
Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management (CPUR or CPUM) preferred

Quality Audit Specialist

About Tenet Healthcare