The Operational Quality Analyst or Operational QA is responsible for the timely and accurate analysis of calls for specified call types including but not limited to Coverage Determination, Appeals, Contingent Therapy, Disenrollment and Grievance. The Operational QA team is a special project devised to essentially perform Quality Assurance Audits on the calls for certain call types deemed critical by the Operations Management and/or the Client, that require special attention and action.
KEY DUTIES AND RESPONSIBILITIES:
- Review calls for the specified call types using the applicable call recording system and the Medicare Services Platform to make determination on whether or not the Member Services Representatives follow the correct action based on the prescribed process.
- Take all steps required, such as utilizing all available resources (Process & Procedure documents, Standard Operating Procedure documents, Job Aids, CMS Guidance Chapters, Google, Claims Processing systems, etc.), in order to effectively carry out the necessary research to complete the task.
- Take appropriate action, based on the identified error, to correct the behavior by sending a detailed and concise Coaching Opportunity email escalation to the Member Services Supervisor and Manager.
- Review and escalate for correction errors in processing that go against the CMS and/or internal operations guidelines.
- Prepare detailed and accurate reports, including but not limited to Start of Shift Audit Assignment Report, End of Day Consolidated Audit Report, and Monthly or Quarterly Audit Analysis Reports, as requested by Management.
- Prepare and maintain Audit Process documentations as required by Management.
- Create and maintain trackers or Excel spreadsheets relevant to day-to-day audit activities as required.
- Continuously work with Management to improve the existing Audit guidelines as necessary.
- Report any system related issues encountered during the audit process.
- Display positive demeanor, technical accuracy, and conformity to company policies.
- Understand CMS Guidance and ensure that all action is in accordance with CMS Guidance.
- Ensure HIPAA regulations are maintained within the immediate environment.
- Documentation is detailed and concise as it pertains to member records.
- Identifies need for outbound calls for purposes of validating information and coordinates with onshore counterparts to request member outreach.
- Communicate with coworkers, management, staff, customers, and others in a courteous and professional manner.
- Conform with and abide by all regulations, policies, work procedures and instructions.
- Respond promptly when replying to correspondence.
- Act, dress, and behave in a professional manner to reflect a positive image of the company.
EDUCATION AND EXPERIENCE:
- Three to five years customer service experience in a federally regulated or insurance related field.
OTHER DUTIES AND RESPONSIBILITIES
- Responsible for compliance with all federal, state and local laws, rules and regulations affecting Company.
- Responsible for participating in quality assurance, compliance and in-service and continuing education activities as requested by Company.
- Responsible for performing other duties and responsibilities as required.
Knowledge, Skills, and Abilities:
- Excellent written, verbal and interpersonal communication skills
- Excellent organizational skills and attention to detail
- Excellent documentation skills
- Team player
- Excellent management skills
- Ability to provide clear and accurate information through multiple media
- Ability to extrapolate, from historical trends, future volumes and staffing needs
- Ability to manage open requests and follow up when necessary without outside direction
- Ability to effectively manage time with strong attention to detail
- Ability to read and interpret documents including safety rules, operating and maintenance instructions, procedure manuals and general correspondence
- Ability to write routine reports and correspondence
- Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals
- Ability to carry out instructions furnished in written, oral, or diagram form
- Ability to deal with problems involving several concrete variables in standardized situations
- Ability to politely, tactfully and firmly interact with a wide range of people and personalities
- Ability to work in an environment with potential interruptions
- Ability to manage multiple simultaneous tasks with individual timeframes and priorities
- Ability to motivate and encourage a team of front line employees
- Ability to set and manage to expectations for a team responsible for direct customer contact
