Quality and Performance Consultant

HCSC•Nashville, TN

5d•Remote

About The Position

This position is responsible for completing trending and analysis of quality results; coordinating Quality of Care (QOC) case intake, triage, tracking, and assignment activities; conducting assigned focus audits across various lines of business; drafting executive summary documents and case-related reports to capture performance results; facilitating meetings and collaboration with internal business partners; drafting solutions to address trends and quality concerns; consulting on specific items impacting quality performance; working with operational areas to evaluate quality programs; maintaining case documentation, medical record requests, and reporting requirements; and communicating the value and impact of quality improvement initiatives while ensuring compliance with established quality standards, regulatory requirements, and performance targets.

Requirements

Bachelor’s degree and 2 years’ experience in claims processing, contract and benefit administration within the health insurance industry OR 6 years’ experience in claims processing, contract and benefit administration within the health insurance industry.
Experience analyzing and resolving problem claims and customer service issues.
Knowledge of claims, inquiry OR membership processes and procedures.
1 year of experience leading meetings or small groups.
Experience with quality assessment and process improvement practices.
Clear and concise written and verbal communication skills.
Research, analytical, critical thinking and problem-solving skills.
Organizational and time management skills.

Nice To Haves

Experience utilizing MHK, Facets, Salesforce Health Cloud, DentaQuest, EPIC, or similar healthcare systems to research claims, eligibility, clinical information, and services rendered.
Experience reviewing, triaging, and assigning cases in accordance with established workflows and service-level expectations.
Ability to collaborate with internal stakeholders to clarify member complaints, investigate issues, and obtain additional information as needed.
Experience creating, maintaining, and organizing case documentation in accordance with departmental standards.
Experience preparing case summaries, supporting documentation, and quality review materials for clinical staff and leadership.
Experience requesting, tracking, and managing medical records and associated documentation.
Three (3) or more years of quality review, quality improvement, or healthcare quality management experience.
Two (2) or more years of experience supporting Quality Management, Grievance and Appeals, or related healthcare operations.
Knowledge of CMS regulations, NCQA standards, HEDIS, CAHPS, HOS, and healthcare quality improvement methodologies.
Experience within Medicare, Medicaid, or other government-sponsored healthcare programs preferred.
Strong organizational, analytical, and documentation skills with the ability to manage multiple cases and deadlines simultaneously.
Proficiency with Microsoft Office applications, particularly Excel, Word, and Outlook.
Associate degree in Arts, Science, Healthcare Administration, Business, or a related field preferred.

Responsibilities

Completing trending and analysis of quality results
Coordinating Quality of Care (QOC) case intake, triage, tracking, and assignment activities
Conducting assigned focus audits across various lines of business
Drafting executive summary documents and case-related reports to capture performance results
Facilitating meetings and collaboration with internal business partners
Drafting solutions to address trends and quality concerns
Consulting on specific items impacting quality performance
Working with operational areas to evaluate quality programs
Maintaining case documentation, medical record requests, and reporting requirements
Communicating the value and impact of quality improvement initiatives
Ensuring compliance with established quality standards, regulatory requirements, and performance targets