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Senior Quality Assurance Analyst

2 months ago

Minneapolis, Minnesota, United States Contech Systems Full time
Job Summary

We are seeking a highly skilled and experienced Senior Quality Assurance Analyst to join our team at Contech Systems. In this role, you will be responsible for end-to-end business process activities, including creating, controlling, and improving performance guarantee processes related to Prior Authorization and Appeals.

Key Responsibilities
  • Process Improvement Initiatives:
    • Create, control, and enhance performance guarantee processes related to Prior Authorization and Appeals.
    • Diagnose process improvement opportunities and develop solutions using principles of process excellence.
    • Oversee quality improvement projects and teams within the functional area.
  • Compliance and Quality Control:
    • Ensure program compliance and quality control for adherence to audit requirements based on state and federal regulations.
    • Serve as the regulatory subject matter expert during oversight and delegation audits performed by various clients.
    • Lead data validation efforts for Prior Authorization and Appeals, including quality control for adherence to accreditation, state, and federal program requirements.
  • Quality Reporting and Analysis:
    • Perform clinical reviews on all DOI inquiries to ensure the PA and appeal process aligns with regulatory guidance.
    • Analyze and report Out-Of-Compliance (OOC) data to identify trends and process improvements.
    • Provide audit and regulatory support related to Prior Authorization and Appeals for all clients of Contech Systems.
  • Continuous Quality Improvement:
    • Develop and implement Total Quality Management (TQM) programs surrounding PA and Appeal-related performance guarantees.
    • Assist in the design, facilitation, training, and evaluation of TQM incentive programs.
    • Evaluate and improve processes to ensure compliance with applicable state and federal laws and business contract requirements.
  • Collaboration with Cross-Functional Teams:
    • Work closely with cross-functional teams to support the creation, implementation, and evaluation of quality improvement plans and programs.
    • Ensure clinical validation of prior authorization cases based on individual plan formulary requirements and patient demographics.
    • Maintain strong client relations by preventing untimely cases and ensuring compliance with business and regulatory requirements.
Qualifications
  • Education: Bachelor's degree in Healthcare, Business Administration, or a related field.
  • Experience:
    • 5+ years of experience in healthcare, preferably in a regulatory, quality improvement, or process management role.
    • Demonstrated experience with Prior Authorization and Appeals processes.
    • Strong understanding of state and federal regulations and accreditation requirements related to healthcare operations.
  • Skills:
    • Strong analytical and problem-solving skills, with experience in root cause analysis and process improvement.
    • Excellent communication and interpersonal skills, with the ability to collaborate effectively across departments.
    • Proficiency in data analysis and reporting tools, such as Excel and SQL.
    • Knowledge of Total Quality Management (TQM) principles and tools.
  • Preferred Qualifications:
    • Experience with auditing and regulatory compliance in healthcare.
    • Familiarity with Contech Systems or similar healthcare systems.