Performance Quality Analyst II

Elevance Health•St. Louis, MO

4d•Hybrid

About The Position

Performance Quality Analyst II Location: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Performance Quality Analyst II is responsible for driving service quality excellence by evaluating the quality of services and interactions provided by organizations within the enterprise. Included are processes related to enrollment and billing and claims processing, as well as customer service written and verbal inquiries. How you will make an impact: Assists higher level auditor/lead on field work as assigned and acts as auditor in charge on small and less complex audits. Participates in pre and post implementation audits of providers, claims processing and payment, benefit coding, member and provider inquiries, enrollment & billing transactions and the corrective action plan process. Demonstrates ability to audit multiple lines of business, multiple functions, and multiple systems. Analyzes and interprets data and makes recommendations for change based on judgment and experience, applies audit policy, and assesses risks to minimize our exposure and mitigate those risks. Works closely with the business to provide consultation and advice to management related to policy and procedure identified as out of date or incomplete and investigates, develops and recommends process improvements and solutions. Functions as a subject matter expert for discrepancy review, questions from team and business partners, and interpretation of guidelines and audit process. Acts as a mentor to peer auditors, providing training and managing work and projects as necessary.

Requirements

Requires a BS/BA
a minimum of 3 years related experience in an enrollment and billing, claims and/or customer contact automated environment (preferably in healthcare or insurance sector), including a minimum of 1 year related experience in a quality audit capacity
or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

WGS Commercial Claims processing experience strongly preferred.
Experience/knowledge with local claim processing.
Understanding of individual member benefits and cost shares preferred.
Understanding of small, large and national group benefits and cost shares preferred.
Understanding of provider contract language.

Responsibilities

Assists higher level auditor/lead on field work as assigned and acts as auditor in charge on small and less complex audits.
Participates in pre and post implementation audits of providers, claims processing and payment, benefit coding, member and provider inquiries, enrollment & billing transactions and the corrective action plan process.
Demonstrates ability to audit multiple lines of business, multiple functions, and multiple systems.
Analyzes and interprets data and makes recommendations for change based on judgment and experience, applies audit policy, and assesses risks to minimize our exposure and mitigate those risks.
Works closely with the business to provide consultation and advice to management related to policy and procedure identified as out of date or incomplete and investigates, develops and recommends process improvements and solutions.
Functions as a subject matter expert for discrepancy review, questions from team and business partners, and interpretation of guidelines and audit process.
Acts as a mentor to peer auditors, providing training and managing work and projects as necessary.