Specialist - Quality

Job Description

Role & responsibilities Assesses the Quality Assurance process and actively looks for opportunities to increase efficiency and proactively brings to Leadership attention. Evaluate operational and management Quality Audit policies/procedures and provide input into the annual review workplan. Performs Quality reviews across multiple clients, working in a variety of host systems. Coordinate with service line leaders and partner with upper level Leadership, to identify areas of risk and assist leadership in developing a quarterly/ annual review plan. Develop a thorough understanding of business processes in scope for assigned reviews and document the processes. Perform account level review to ensure consistency with best practices including but not limited to Quality Audit to confirm implementation and effectiveness of policies/procedures. Performs reviews to measure compliance with policies, procedures, workflow, and other applicable requirements. Identify and document operational, compliance, and quality risks and make recommendations to mitigate risks. Prepare and assist in presenting quality reports of review findings and recommendations to direct leadership for review and approval. Participate in pre- & post-review meetings, providing support and recommendations for issues presented. Ensure past review recommendations are implemented in the current review process. Maintain current knowledge of laws/regulations regarding medical necessity, clinical documentation, compliance standards, other general clinical and/or business matters related to the service line they are working. This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Associates may be required to perform other job-related duties, requirements, or working conditions associated with the job. Associates may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation. Preferred candidate profile Graduate in any discipline (B.Sc./M.Sc. Nursing, B. Pharm, M. Pharm, or Life Sciences education is preferred) Certification in Medical Billing and Coding (CPC, CCS, or equivalent) preferred. 3+ years of overall experience with 2+ years of experience in Quality Analysis within the healthcare / RCM domain. Strong understanding of end-to-end RCM processes including charge entry, payment posting, denial management, and AR follow-up. Knowledge of HIPAA and healthcare compliance standards. Proficiency in using billing software (e.g., Epic, Athena, Kareo) and QA tools. Excellent communication skills for feedback and reporting.