Quality Analyst/Auditor- Hansen- Full Time
About The Position
The Quality Analyst/Auditor manages quality-related aspects of insurance contracts to help ensure Prevea Health receives negotiated reimbursements for meeting required quality metrics. The role reviews medical records and payer data and collaborates with providers and leadership to support accurate documentation, compliance, and strong quality performance tied to insurance contracts. The position supports contract and program implementation, interprets quality requirements and performance thresholds, prepares audit reports, monitors contract performance, and recommends corrective actions when gaps are identified. It also helps develop educational materials and guidance for providers and staff, and identifies opportunities to automate quality data extraction using EPIC or other data sources. The role collaborates with the Clinical Optimization Team, Chief Quality Officer, Chief Financial Officer, and physicians and clinicians to develop and implement best practices for quality-related workflows.
Requirements
- Associate's degree in Healthcare Administration or a technical diploma in a healthcare-related field.
- Strong analytical, auditing, and organizational skills.
- Ability to communicate effectively with providers, leadership, and cross-functional teams.
- Understanding of medical record documentation and coding guidelines.
- Knowledge of medical insurance claims processes.
- Familiarity with insurance contracts.
Nice To Haves
- Two or more years of healthcare-related work experience.
- Clinical experience as a medical assistant (MA) or licensed practical nurse (LPN).
- Experience with electronic medical records, EPIC, and Microsoft Office.
- Familiarity with quality measures such as HEDIS.
Responsibilities
- Review medical records, extract data for quality and audit metrics, and verify documentation and coding accuracy.
- Review insurance payer reports and data, and conduct audits and medical record validation.
- Assist with implementing new contracts and programs, ensuring workflows and processes meet quality metric requirements.
- Develop educational materials and provide guidance to providers and staff on quality metrics, documentation standards, and contract requirements.
- Analyze quality-related terms in assigned insurance contracts and amendments, and communicate measure requirements and performance thresholds.
- Prepare audit reports and streamline workflows to meet monthly, quarterly, and annual quality and performance goals.
- Monitor assigned contract performance, identify gaps in quality requirements, and recommend and support corrective actions.
- Identify and support opportunities to automate quality data extraction using EPIC or other data sources.
- Collaborate with the Clinical Optimization Team, Chief Quality Officer, Chief Financial Officer, and physicians and clinicians to develop and implement best practices for quality-related workflows.
Benefits
- Continuous education, training, and support.
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
