PHRN Quality Analyst
Full-time
Omega Healthcare Management Services, Inc.
- Prioritize incoming authorization and referral requests according to queue urgency
- Review patient’s clinical and chart documentation related to the service submitted by the provider’s office
- Obtain and/or follow up on authorization and referral requests from the patient’s payer/s through any of the following methods—depending on the payer’s policy:
- Perform outbound calls to payer’s authorization department
- Access payer’s authorization online portal
- Submit faxes to payer’s authorization department
- Respond to payer’s clinical questions to be able to proceed with the authorization and referral requests
- Obtain and/or follow up payer’s peer-to-peer review requirements and send them back to provider’s office for the actual initiation
- Cater inbound calls from payers and perform necessary actions required for the task
- Listen and review voicemail messages from payers then perform necessary actions required for the task
- Monitor activities of Nurses to assess schedule adherence, accuracy, quality, productivity, timeliness and compliance with job requirements, policies and procedures. Report updates to management.
- Provide basic on-the-job training for direct reports and serve as a resource to address questions related to the policies, processes and procedures.
- Delivers required number of QA Monitors on a timely manner
- Provide quality metric analysis on compliance scores
- Participates in call calibration to understand and identify targets
- Generates and trends daily/weekly/monthly QA related reports
- Performs side-by-side sessions and provide real-time feedback
- Skilled in pinpointing root cause/s for performance variance
- Provide recommended intervention activities to address quality metric opportunities identified
- Solid understanding of anatomy & physiology, including how body systems function and an understanding of disease processes
- Comprehensive understanding of Medical Terminology
- Prior experience in processing multispecialty authorizations including contact with payers
- Experience in prior authorization process
- Experience with general computer software (Internet, Word, Outlook, PDF required)
- Proficiency to learn new software programs quickly
- Excellent customer service skills: communicates clearly and effectively
- Excellent verbal and written communication skills
- Professional and effective interaction skills with co-workers, clients, providers, and vendors
- Proven ability to work well individually and as a team member
- Strong attention to detail
- Ability to follow company and account-specific standard operating procedures and policies
- Ability to adapt to constantly changing environment
- Ability to prioritize and organize multiple tasks by remaining focused and quality-driven at all tasks at hand
- Ability to remain organized with multiple interruptions
- Ability to make decisions independently without bypassing any company and account-specific standard operating procedures and policies
- Ability to comfortably receive constructive feedback
- Graduate of Bachelor of Science in Nursing with active PH registered nurse license
- 1 year of experience of US healthcare authorization business
- At least 2 years of experience in the BPO/Healthcare industry is an advantage
- Bachelor's Degree in Nursing with active PH Registered Nurse license
- Minimum 2 years of Quality Analyst experience in a US Healthcare account (Prior Authorization or Claims/Denial/Appeal)
- Excellent Leadership & Interpersonal relationship
- Strong Process Management & planning skills
- Embrace change and think operationally to achieve business goals
- Proven process improvement experience
Required Skills
Requirements
Vacancy posted 2 days ago
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