Job Details

ID #19583186
State Pennsylvania
City Philadelphia
Job type Permanent
Salary USD TBD TBD
Source Amerihealth
Showed 2021-09-14
Date 2021-09-02
Deadline 2021-11-01
Category Et cetera
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Medicare Quality Control Analyst

Pennsylvania, Philadelphia, 19107 Philadelphia USA

Vacancy expired!

Your career starts now. We're looking for the next generation of health care leaders. At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you. Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

Responsibilities:
  • The Quality Control Analyst will support the Director and Manager of Operation Oversight and Quality Control with Quality Control of end to end operational activities, implementations, regulatory audits and initiatives for all Medicare Health Plans. Duties include but are not limited to the below:
  • Responsible for conducting monthly mock CMS audits in accordance to CMS audit protocols; weekly and or monthly random and target audits of all operational areas against CMS, State and 3-way contract requirements to identify gaps and compliance issues. This data will be reported to all functional area leaders to gain insight into areas requiring attention in order to mitigate risks and meet regulatory requirements.
  • Supports internal and external audit activity serving as the subject matter expert for all Medicare LOBs including CMS and operation integrity audits. Coordinates file pulls, data requests, universe development, QC and supporting documentation. Partners with Compliance lead to monitor development and execution of corrective action plans to remediate deficiencies identified by internal audits and/or external regulatory bodies.
  • Evaluation of Policy and Procedures, Workflow, Desk Level Procedures and Training Material for the functional areas assigned to determine accuracy, completeness and compliance with all regulatory bodies, Plan and/or departmental requirements.
  • Develop back end reporting, analyze data and provide insight into areas requiring attention in order to mitigate risks and save compliance.
  • Complete and supply daily report cards by functional area (to be defined as part of the program being developed) to the Manager and Director of Operations Oversight and Quality Control.
  • Address and respond to appeals, monitor mitigation solutions both short term and long term.
  • Complete daily quality control check lists and attestations.
  • Work with Manager and Director to strategize on risk mitigations plans and monitoring for execution.
  • Review and interpretation of HPMS memorandums and quarterly releases and CMS Chapter Changes. Identify how CMS changes will impact current processes for all functional areas and works directly with each functional area to monitor implementing and execution of the changes needed to the impacted operational systems, workflows, policies, procedures, etc.
  • Ongoing tracking and monitoring of all Medicare LOBs policy and procedures to ensure annual updates are occurring timely as well as when regulatory changes occur impacting such.
  • Quality Control of new business implementation, Medicare initiatives and Regulatory changes in advance of execution to production/go-live.
  • Assist and perform duties as back up to the Operations Oversight Analysts.

Education/ Experience:
  • High School/GED.
  • Bachelor's Degree preferred.
  • Microsoft Office - Excel, Access, Word, Outlook, Project, Visio.
  • Facets/TMS Suite of Products, JIVA.
  • CMS Medicare technical experience and understanding of regulatory requirements.
  • Extensive Medicare Operations experience.
  • Extensive operations knowledge and experience.

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