Sorry, this job is no longer accepting applications. See below for more jobs that match what you’re looking for!

Quality Review/Audit Sr Spec

Expired Job

Cigna Nashville , TN 37201

Posted 5 months ago

Position Summary The Quality Review/Audit Sr. Specialist works very closely with the Operations Senior Specialist-Compliance to assure a good flow and consistency between Non-Clinical Training/ Quality Process and Clinical Training / Quality Process. Both will also work together to make sure we follow any Compliance guidance.

This role is also responsible for managing a team of Non-Clinical Trainer / Quality Reviewer, based in different market. Main accountabilities of this role will be to provide adequate Training and Quality review for Non-Clinical resources within PreCert Department.

Essential Duties and Responsibilities

  • Manage and update the Quality Improvement program to Precert Staff. Audit documentation generated through the calls and develop quality and performance measurements.

  • Manage a remote team of Trainer / Quality Reviewer based in different market and maintain unique "customer experience" in the team across market.

  • Responsible for the analysis of quality measurements to simplify and/or improve processes, as well as tracking and trending data to determine performance standards.

  • Monitor, track and provide monthly Highlights and findings about following components: Quality and Training.

  • Works closely with the corporate training department to determine additional training needs including management training, reference materials, job aides, coaching, communication, etc.

  • Works closely with PreCert leadership team to assure we are meeting their needs and provide them adequate feedback about their staff.

  • Works closely with your peers to maintain consistency, avoid duplication and share best practice across the team, which include Non-Clinical, Clinical, Compliance, C-Kit pages information, PPAL and data analytic resources.

  • Provide constructive feedback to individuals or groups regarding audit findings and coach the staff on appropriate departmental processes and guidelines to facilitate process improvements.

  • Develops and maintains all necessary training scenario applications for the Health Services department.

  • Providing new and existing staff with training and conducting training in variety of modalities, including role playing, simulations, team exercises and group discussions. Monitors and measures staff training progress and development

  • Facilitates performance improvement plans for identified personnel and makes recommendations to Health Services leadership in areas of process and performance improvement strategies for both individuals and teams.

  • Actively participates in all staff meetings.

Knowledge, Skills, Abilities Required :

  • Advance knowledge of the Precert Process

  • Knowledge and ability to train on Precert processes

  • Advance knowledge of Utilization Review principles

  • Knowledge of Medicare Review Criteria and ability to train the trainer on how to use the criteria.

  • Ability to identify and analyze problems and recommend solutions.

  • Possess excellent analytical skills.

  • Extensive knowledge of medical management processes including authorization rules and contracting methodology.

  • Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners, Executive Leadership, and other health workers involved in the care of a member

  • Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments

  • Able to work in a dynamic, fast-paced team environment and to promote team concepts

  • Proficiency with Excel and with analytical tools, knowledge of data analysis methodology, use of presentation software.

  • High Degree of knowledge of formal and informal departmental goals, standards, policies and procedures which may include some familiarity of other departments within the organization.

  • Ability to work well independently and with little need for supervision.


See if you are a match!

See how well your resume matches up to this job - upload your resume now.

Find your dream job anywhere
with the LiveCareer app.
Download the
LiveCareer app and find
your dream job anywhere

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Quality Review/Audit Sr Assoc Healthspring (Nashville TN)


Posted 1 week ago

VIEW JOBS 12/6/2018 12:00:00 AM 2019-03-06T00:00 This will include assisting in the development of audit tools and recommending changes in processing procedures. As a member of the Customer & Client Service Experience (CCSE) Ops Internal Monitoring Team, the incumbent will have the ability and be expected to drive change, and positively impact the accuracy and efficiency of Cigna Healthspring's operations by recommending actions that address error trends and root-causes of errors found during quality audits. Responsibilities: * Complete assigned audits in a timely manner * Follow up and respond to inquiries from the auditee regarding audit work performed * Identify and report error trends to Management * Work with management in developing appropriate remediation steps to address audit findings and error trends * Train other auditors and create job aids and other related material for the CCSE Ops Internal Monitoring department * Develop subject matter expertise in areas audited and become resource for the team * Ability to meet production demands and maintain a high level of quality. This may include occasional overtime, especially during the peak seasons * Supports and drives process improvement to further enhance service outcomes; opportunities for streamlining processes and procedures, reducing rework * Supports and reinforces updated and/or new information; SOPs, tools, system enhancements, workflows, etc. Qualifications: * High School Diploma required; Bachelor's Degree preferred * 3-5 years of experience in a healthcare environment. Knowledge and proficiency in one or more Medicare functional areas Part C and or Part D (Customer CARE, Coverage Determination, Organization Determination, Appeals, Grievance). * Experience with QNXT and Verint systems preferred. * Proficiency in Excel, Outlook, Word and Sharepoint. * Must possess strong analytical and critical thinking skills. * Must demonstrate a desire to learn new skills and willingness to adhere to departmental procedures. * Excellent oral and written communication skills and ability to interact effectively with staff at all levels of the organization. * Possess an understanding of operational auditing * Ability to work independently and collaboratively with colleagues within department and other areas of the company. * Ability to meet strict timelines * Detail oriented Cigna Nashville TN

Quality Review/Audit Sr Spec

Expired Job