Quality Management Specialist

OUTCOMES OPERATING INC•West Des Moines, IA

1d•Hybrid

About The Position

Evaluate and enforce policies and procedures to maintain the quality of claims documented in Outcomes programs, collaborate with internal stakeholders to identify and outline quality standards as they relate to projects and processes that pose potential risk for quality related issues or fraud, waste and abuse (FWA). Analyze data, reports, operating practices, and documentation as part of the standard monthly claims close and internal auditing processes to ensure quality in business processes.

Requirements

Applies working knowledge in the application of concepts, principles and technical capabilities to perform varied tasks
Works on projects of moderate scope and complexity
Identifies possible solutions to a variety of technical problems and takes action to resolve
Applies judgment within defined parameters
Receives general guidance and may receive more detailed instruction on new projects
Work reviewed for sound reasoning and accuracy
Healthcare experience strongly preferred
Ability to meet multiple deadlines
Strong written and verbal communication skills
Ability to communicate across all levels of an organization, demonstrating professionalism and good judgment at all times
Must be able to work autonomously (with minimal direction) while also being part of an integrated team
Must be able to manage competing demands and multiple priorities, while maintaining a strong attention to detail
Strong quantitative, qualitative, and analytical skills including technical proficiency related to PC and basic office software
Minimum years of work experience: 2 years
Minimum level of education or education/experience: Bachelors or equivalent work experience in healthcare operations, preferably Medication Therapy Management or member patient communications

Nice To Haves

IN healthcare is preferred

Responsibilities

Demonstrate in-depth understanding of the business model, claim submission requirements and claim validation specifications
Develop and manage an inventory of quality assurance system edits and coordinate with other departments to adjust, as needed
Identify and resolve MTM activity issues and complete fraud, waste, and abuse monitoring by analyzing data, reports, operating practices, and documentation as part of standard monthly claims close and internal auditing processes to ensure compliance
Develop and maintain network educational materials related to policies, procedures, and documentation requirements, including the policy and procedure guide
Coordinate across departments to develop responses to client quality audits
Strategize, execute, and monitor corrective action plans for quality related incidents
Review daily data quality reports, identify inconsistencies and opportunities for improvement
Provide quality assurance support across the business including reporting, processes and other areas as assigned

Benefits

Medical, Dental and Vision Plans
Voluntary Benefits
HSA & FSA
Fertility and Family Planning Benefits
Paid Parental Leave
Adoption Assistance Program
Employee Resource Groups
Flex PTO for Exempt Associates and up to 15 PTO days in first year of employment for non exempt associates
11 Paid Holidays
Corporate Wellness Program
401(k) plan offering both pretax and Roth contributions, plus an employer match