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.