Analyst-Quality Assurance

Overview

Job Summary

Quality Assurance Analysts evaluate the adequacy and effectiveness of internal and operational controls designed to ensure that processes and practices lead to appropriate adjudication of claims. This role requires thorough understanding of regulatory requirements, managed care contract terms, facility-specific internal guidelines, revenue integrity, billing, cash applications, payment variances and adjustment processing including federal and state regulations and guidelines.

Responsibilities

• Conduct audits to determine organizational integrity of upstream, midstream and downstream revenue cycle activities that impact the adjustment processing of claims.
• Conducts risk assessments to define audit priorities by evaluating previous audit findings, management priorities and current volumes of adjustments.
• Complete special AR projects to help liquidate key segments of Baptist aging AR
• Review all timely filing adjustments to determine whether Baptist has exhausted all attempts to appeal and overturn timely filing denials.
• Communicate audit results to hospital service departments and departmental leadership, and make recommendations for management corrective action.
• Serve as institutional subject matter experts and authoritative resources on interpretation of contract language to ensure appropriate reimbursement by insurance companies.
• Performs scheduled and unscheduled independent audits of revenue integrity and business office activities.
• Conducts routine retrospective and prospective account audits as directed by revenue cycle system director.
• Assess internal and external communication of changes to better communicate across functional departments
• Adheres to the defined audit timeline and audit protocol standards; assists with development of the audit schedule; identifies services to be audited.
• Annually identifies specific needs for self-development and implements a plan to achieve professional growth.
• Applies consistent and standardized compliance audit methodology for sample selection, scoring and benchmarking, development and reporting of findings and repayment calculations.
• Prepares written reports of audit findings and recommendations and presents to specific business offices; evaluates the adequacy of management corrective action to improve deficiencies; maintains audit records
• Participates in the development of the department long-term and short-term goals, objectives plans, policies and procedures.

Specifications

Experience

Minimum Required

• 2 years of experience in the healthcare industry with a working knowledge of hospital or physicians revenue cycle functions.

Preferred/Desired

Education

Minimum Required

• High school diploma or equivalent

Preferred/Desired

• Associates Degree related to health care or information technology

Training

Minimum Required

• Understanding of industry-specific terminology; Managed Care policy manuals and contractual expected reimbursement

Preferred/Desired

• Detailed knowledge of revenue cycle work streams and revenue flow; Revenue cycle process management; Moderate systems expertise; Moderate experience with facility and professional billing requirements

Special Skills

Minimum Required

Preferred/Desired

Licensure

Minimum Required

Preferred/Desired