SCOPE OF ROLE

The Quality Assurance Analyst is responsible for ensuring the proper completion and accuracy of chart documentation. Duties include but are not limited to: Consistently and accurately assess for Quality Assurance of utilization reviews for all programs; Pull and review charts for each assigned program to ensure charts reflect the minimum required Quality Management policy; Report findings to the Utilization Management and Quality Management teams. Consistently and accurately assess tasks assigned; Provide In-Services/ trainings to staff with regards to the quality assurance findings. 

ROLE RESPONSIBILITIES

• The Quality Management Nurse, Utilization Management job description lists essential duties and responsibilities. Other duties may be assigned.
• Participating in the quality oversight program for the utilization management program through auditing and reporting, including communicating status updates, results, and outcomes via written and oral report to Senior Analyst and utilization management quality program leadership.
• Ensure utilization management program policies and procedures are reflected in the documentation audited. 
• Assist with reporting required by state and federal agencies as needed and assigned.
• Assist with the execution of state and federal agency audits, including CMS audits. This may include mock audits, regular data universe audits and process audits.
• Report identified issues found through monitoring to help identify areas and root causes of operational clinical issues that need corrective action and collaborate with the delivery team on the remediation activities including but not limited to training and 1:1 coaching. 
• Ensure entry of data requirements into utilization management platform is consistent, accurate, timely and appropriate per workflow requirements and documentation standards.
• Other activities as assigned
• This position does not have supervisory responsibilities. 
• The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Travel may be required. 

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Associate degree or Bachelor’s degree preferred.
• Active LPN or RN license or similar professional clinical licensure in good standing with current state required. 
• One (1) year of utilization management/quality improvement experience audit experience at a health plan required. 
• Advanced knowledge and understanding of basic utilization management and quality improvement concepts required.
• Knowledge of CMS, URAC and/or State utilization management statutes and standards required.

PROFESSIONAL COMPETENCIES

• Must be self-motivated, able to take initiative, and ability to thrive and drive results in a collaborative environment.
• Must possess strong organizational and prioritization skills and competence and capacity to handle multiple initiatives while managing conflicting priorities.
• Experience with problem management, change control and how to influence change without direct control within a decentralized business unit culture.
• Excellent writing skills, particularly in determination notification writing.
• Ability to develop strong cross-functional and collaborative relationship with internal and external partners, including the ability to work with a wide variety of people and personalities. 
• Experience in using the Microsoft Office Suite including Excel and Word as well as demonstrated ability to learn/adapt to other computer-based systems and tools.