As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

JOB SUMMARY

Responsible for conducting audits to measure Quality Assurance across critical business processes. Complete analytical assessment of work product and processes to identify root cause of incidences and provide feedback to key stakeholders. Prepare reports to communicate QA results and findings to Leadership Team and process owners across the organization, driving accountability and ongoing improvement of QA metrics. Interface with internal customers to act as a functional and operational liaison for the end user group community. Understand policies and procedures and utilize them for daily Quality Assurance duties. Use The QA analyst will be responsible for documenting, and monitoring business processes and associated workflow.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Complete quality assurance inspections as required, ensuring standardization and compliance with established policies and procedures and applicable regulations.

• Identify research and document process improvement opportunities. Then collaborate with internal and external business partners (Operations, Compliance, Facilities, and Payers) to drive accountability and process improvements

• Prepare and review data and QA reporting with key stakeholders.

• Provide input for policies and procedures updates as required.

• Special projects as assigned

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• The Ability to complete the review of a clinical appeal letter using critical thinking skills and practical application of national criteria guidelines, InterQual� (IQ) and Milliman� (MCG) evidenced based medicine.

• The ability to evaluate the appeal letter when the national criteria guidelines are �not met�. This criterion includes co-morbid conditions, the patient age, and the medical predictability of an adverse outcome if the patient is not cared for in the appropriate level of care.

• Must possess a clear knowledge of all clinical activity codes and their practical application to differing dispute scenarios.

• The QA nurse analyst must have a clear understanding of the clinical dispute process, how to review a disputed account in ACE, the client specific Case Management application, the correspondence application, the EMR and any other associated applications such as N-thrive..

• Must have a solid knowledge of patient�s across the lifespan from neonatal to geriatric age groups.

• Possesses excellent written, verbal and professional letter writing skills

• Ability to multi-task
• Ability to conduct research regarding State/Federal appellate guidelines. LCD�s , NCD�s and payer policies and procedures
• Ability to work independently to meet objectives in a repetitive auditing environment.
• Possesses an exceptional eye for detail and process improvement.
• Ability to identify problems, gather and analyze information skillfully and provide recommendations for process improvements.
• Independent, logical thinker with ability to perform detailed data analysis
• Demonstrated ability to build strong working relationships with key internal and external stakeholders (Centralized Operations, Compliance, Facilities) and be a thought leader/influencer for change.
• Advanced troubleshooting abilities, with ability to problem solve complex technical issues
• Must be capable of executing and publishing written requirements utilizing the business intent and goals, while providing technical details to support workflow or system development
• Ability to develop and/or present training to operations trainers and/or business users
• Intermediate level skills in applications such as Microsoft Excel, Word, and Visio
• Additional skills preferred, not required:
  • Knowledge of healthcare revenue cycle
  • Knowledge/experience with system design in a database environment
  • Knowledge of project management methodologies
  • Knowledge of research methodology, principles and procedures

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

• Must possess a valid nursing license (Registered or Practical/Vocational)
• Minimum of 5 years recent medical surgical care experioence with the last 2 years in a facility environment
• Medical-surgical/critical care experience
• Minimum of 2 years UR/Case Management experience within the last 2 years
• Managed care payer experience a plus either in Utilization Review, Case Management or Appeals
• Patient Accounting experience a plus
• Previous classroom led instruction on InterQual� products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred
• Previous classroom led instruction on Milliman�, MCG preferred

• Current, valid RN, licensure
• Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management (CPUR or CPUM) preferred

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to work in sitting position, use computer and answer telephone.
• Includes ability to type, sit for long periods of time, view claims on a computer, and listen to phone calls through headphones.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Office work environment
• Moderate office noise

• Ability to travel 5% of time

Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.