Quality Business Analyst

Role Overview

The Quality Business Analyst works closely with different business units to ensure adherence to defined metrics, company protocols, and procedures. By conducting audits, the analyst highlights opportunities for enhancement, detects discrepancies in systems, and recognizes training needs to advance operational excellence and ensure delivery of superior service to clients and members.

Key Responsibilities

• Conduct comprehensive reviews of operational activities from start to finish to guarantee accuracy and completeness.
• Deliver prompt, documented feedback on identified issues at the processor or system level, and act by escalating concerns when needed.
• Partner with business teams to pinpoint opportunities for improvements and streamline operations.
• Audit transactional operations including provider, member, and vendor communications, claims, appeals, grievances, enrollment, billing, and client setup to verify accuracy and completion.
• Ensure operational practices comply with internal policies and regulatory mandates by reviewing entire operational workflows.
• Propose process improvements and recommend workflow or system changes to enhance operational efficiency.
• Analyze trends and identify root causes of deficiencies to support ongoing quality improvement efforts.
• Design and carry out test plans for new or adjusted processes, guaranteeing compliance with policies and effective function; keep detailed documentation of tests.
• Communicate effectively in both written and oral forms with internal teams and external stakeholders.
• Support project activities by maintaining task-level documentation, tracking deadlines, and serving as a technical liaison as necessary.
• Participate in ongoing internal and external training programs to remain proficient in all relevant systems and procedures.
• Carry out additional duties as assigned.

Qualifications and Skills

• Between 3 to 5 years of experience in quality review, auditing, or claims processing.
• Bachelor’s degree is preferred.
• Proactive self-starter with excellent problem-solving abilities, attention to detail, strong analytical and organizational skills, and proficient writing capabilities.
• Understanding of systems, process flows, and timeline management to ensure compliance throughout requirement testing and implementations.
• Adept at compiling detailed system requirements and using data reporting and mining tools to fulfill business needs.
• Skilled in trend analysis and effective communication of findings and strategic recommendations to business partners, focusing on minimizing negative impact.
• Excellent oral and written communication skills to equip business partners with necessary information for system updates or new system introductions.
• Ability to remain flexible within a team environment, identify process improvement opportunities, and determine related system impacts.
• Experience and working knowledge of healthcare plans, Medicare regulations, claims processing, client setup, and enrollment procedures.
• Basic familiarity with systems such as Front Office System (FOS), HealthRules Payor (HRP), PRIME, Virtual Appeals Manager (VAM), Tableau, and ServiceNow (SNOW).
• Capable of working independently in a hybrid work setting.

Additional Information

The employer is committed to equal opportunity employment practices, considering all qualified candidates without discrimination based on age, race, color, religion, sex, national origin, sexual orientation, veteran status, or disability.

Candidates must possess a compatible Android or iOS device to use the free Microsoft Authenticator application required for authentication purposes.