Registered Nurse OASIS QA Specialist at CenterWell Home Health, ensuring compliance and quality in patient care documentation. Collaborating with clinicians and monitoring quality indicators while leading improvement initiatives.
About the role
- Quality Assurance Auditor performing quality assurance audits for Pharmacy Benefit Dimensions. Ensuring compliance with regulatory requirements and collaborating with teams for effective audit processes.
Responsibilities
- Perform monitoring, oversight, and quality assurance reviews/audits of all lines of business as defined by CMS, NYS DOH, NYS DFS and any/all policies and procedures established (as applicable) for assigned operational areas.
- Ensure the quality and accuracy of the systems and processes that support the organization’s operation to meet client government regulatory requirements and compliance plans.
- Track issues identified during the quality assurance process to ensure resolution.
- Analyze, document, and report on results to business stakeholders and company leaders.
- Collaborate with the Quality Assurance team and other cross functional teams to remediate audit findings, to develop and improve testing and audit strategies, techniques, activities, policies and procedures.
- Conduct internal audits to measure and ensure adherence to claims processing standards, technical requirements, supporting processes, systems, and required program documentation.
- Report quality assurance and audit results to management and leadership teams.
- Perform ad hoc queries in audit database in support of decision making.
Requirements
- High school diploma or GED required.
- Associates degree preferred.
- Three (3) years of experience in quality assurance/quality control, compliance monitoring, pharmaceutical, or managed care environment required.
- Experience with Medicare, Medicaid or another government program strongly preferred.
- Experience with pharmacy on-line claims processing systems preferred.
- Strong analytical, problem solving, time management and organizational skills.
- Ability to use independent judgement and solid reasoning skills when rendering decisions and troubleshooting issues.
- Detail oriented, while maintaining an awareness of overall goals.
- Experience with AS400 query or other query tools.
- Ability to easily learn new software applications.
- Experience in report production.
- Ability to maximize use of system capabilities to lead the organization in outcome improvement.
- Excellent interpersonal, written and verbal communication skills.
- Proven examples of displaying PBD values: Trusted Advisor, Innovative, Excellence, Guardianship, Dedication and Caring.
Benefits
- full range of benefits
- generous paid time off
- scorecard incentive
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