Performs quality control activities of provider data records that have been entered or processed by the Provider Data Management Staff. Provides feedback to management. Identifies, recommends and implements process improvementbased on audit results.
Develops and provides training based on the identified opportunities. Oversight and maintenance of all P&Ps. Auditing of the phone staff for quality measures. Training of internal staff regarding the program updates and/or changes, Coordinates with TriWest training department as needed.
o Develops audit procedures and executes Daily/Weekly/Monthly audits. Provides feedback to staff based on outcome of audit to improve quality.
o Entries and updates into the provider file for network providers based on a statistically significant randomly selected set of records. This may include practitioner and facility provider records.
o Responds to and resolves Bizflow and Track-it Tickets for AnchorPoint system issues; tests fixes
o Conduct exception audits as needed; develops and maintains exception audit processes and procedures; communicates changes to staff.
o Trend reports and analyze to recommend possible solutions to management.
o Provide monthly training updates to management to include suggestions of needed training for departmental staff.
o Develops training materials, conducts training, identifies needs for future training; manages wiki updates.
o Drafts department policies and procedure changes based on knowledge and familiarity with process.
o Develops and updates department desk procedures by developing workflows utilizing understanding of programs.
Education & Experience
o Bachelor's (BA/BS) Degree in health care or related field or equivalent experience
o 3 years of managed care experience (provider contracting and/or provider data) or experience working for a health care provider, with increasing responsibility.
o Excellent written and verbal communication skills.
o 2 years documented quality auditing experience.
o 2 years TRICARE and/or VA experience
o Previous training experience
o Ability to function under minimal supervision and make independent judgments.
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