healthcare quality analyst

Med-Metrix

Job Purpose
<br>The Quality Analyst supports quality auditing, analysis, reporting and the development of plans that lead to positive outcomes. The Quality Analyst will work on risk identification, diagnosing issues, identifying process improvement solutions and process improvement implementation methods utilizing sound principles. Continuous engagement and collaboration with the Operations and Training Team is essential.
<br><br>
Duties & Responsibilities
<br><ul>
<li>Ensure that project related quality processes are followed by denials analyst and client specific and internal metrics are achieved</li>
<li>Prepare detailed reports on audit findings and understand the quality requirements both from process perspective and for targets. Deliver reports in a timely manner.</li>
<li>Identify a method to achieve the quality targets and implement the same in consultation with QCA lead and/or managers. Assist with the Quality Assessment process to ensure all quality standards targets can be met.</li>
<li>Participate in performance improvement activities and continuing education to maintain current credentials and enhance knowledge and skills</li>
<li>Share all relevant information with the team and take initiative to ensure team members get projects completed</li>
<li>Participate in client presentation of findings, when requested</li>
<li>Adjust workloads as necessary to achieve successful completion of project</li>
<li>Handle complaints, questions, and queries as necessary</li>
<li>Disseminates changes in guidelines and rules; monitor changes in laws, regulations, and policies that impact clinical documentation, reimbursement to assure compliance</li>
<li>Foster an environment of teamwork and service excellence within the department</li>
<li>Participate in conference calls/meetings with management and staff to ensure all performance and training recommendations are addressed and improvement suggestions are implemented</li>
<li>Assist in new hire training classes, transition periods and refresher trainings as needed</li>
<li>Maintain knowledge, understanding of, and compliance with all Med-Metrix policies and procedures.</li>
<li>Participate in presentations to educate staff on outcomes and plans of correction</li>
<li>Perform other duties as necessary</li>
<li>Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards</li>
<li>Understand and comply with Information Security and HIPAA policies and procedures at all times</li>
<li>Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties</li>
</ul>
Qualifications
<br><br>
<ul>
<li>At least 2 years previous work experience as a Quality Analyst in healthcare insurance collections, self-pay collections and customer service in a call center setting or compliance and/or training</li>
<li>Experience with training new users</li>
<li>Knowledge of EOBs, CPT & ICD-9 & 10 codes, HCFAs, UB92s, HCPCS, DRGs and authorizations/ referrals.</li>
<li>Strong understanding of the basic healthcare revenue cycle operational processes such as the functions of insurance, patient billing & collections, Managed Care, Medicare, Medicaid, and Commercial Practices</li>
<li>Experience with practice management systems. EPIC PB, Allscripts and/or Cerner preferred</li>
<li>Knowledge of the denied claims and appeals process</li>
<li>Must have an experience in outbound transaction AR process (Payers)</li>
<li>Ability to navigate through multiple software and computer applications</li>
<li>Detail oriented and well organized</li>
<li>Capacity to maintain a high level of objectivity when completing staff reviews</li>
<li>Proficient computer skills including Microsoft Office Suite, intermediate Excel skills required</li>
<li>Self-motivated and resourceful with the ability to multitask and successfully operate in a fast paced, team environment</li>
<li>Ability to work well individually and in a team environment</li>
<li>Strong analytical and organizational skills</li>
<li>Strong interpersonal skills, ability to communicate well at all levels of the organization</li>
<li>Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses</li>
<li>High level of integrity and dependability with a strong sense of urgency and results oriented</li>
<li>Ability to meet assigned deadlines and work under minimal supervision and with all levels of staff and management.</li>
<li>Excellent written and verbal communication skills required</li>
<li>Gracious and welcoming personality for customer service interaction</li>
</ul>
Working Conditions
<br><br>
<ul>
<li>Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.</li>
<li>Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.</li>
<li>Work Environment: The noise level in the work environment is usually minimal.</li>
</ul>
Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.

4.230_HB ARS Mgmt_Quality Analyst

CareSource

<div><div>Job Summary:</div><div></div><div>
The Quality Analyst III is responsible for analyzing and interpreting complex healthcare data. This role will collaborate with cross-functional teams, providing analytical insight to inform strategy and interventions to drive improved quality performance</div><div></div><div>
Essential Functions:</div><ul><li>
Generate comprehensive reports, graphics and dashboards that effectively summarize and display data for key stakeholders</li><li>
Review reports and data for pattern identification, special cause variation identification, trend analysis, or other techniques and provide management level summaries that explain key findings</li><li>
Provide technical expertise and guidance to team members on SQL, SAS, and DAX coding best practices, visualizations, and table locations</li><li>
Interpret and maintain understanding of technical specification and other quality reporting requirements and ensure any changes are implemented and communicated with key stakeholders timely</li><li>
Interact and work collaboratively with business partners on analysis, reports and data patterns to identify trends</li><li>
Gather, understand and refine requirements for analytics requests including but not limited to HEDIS, Population Health, Pharmacy Quality, Accreditation, Health Equity, business development and RFP requests</li><li>
Collaborate with IT teams to enhance data collection and reporting systems</li><li>
Perform any other job duties as assigned</li></ul><div></div><div>
Education and Experience:</div><ul><li>
Bachelor of Science/Arts degree in Management Information Systems (MIS), computer science or related field or equivalent work experience is required</li><li>
Master of public health (MPH), Business Administration (MBA), mathematics, statistics, or related field is preferred</li><li>
Minimum of three (3) years of experience in data analysis and/or analytic programming is required</li><li>
Minimum of three (3) years of HEDIS or similar healthcare quality performance metrics experience is required</li><li>
3-5 years Programming experience (i.e., SQL, SAS) is required</li><li>
Programming in DAX/Power BI is preferred</li><li>
Health care delivery, clinical experience and/or payer experience is preferred.</li></ul><div></div><div>
Competencies, Knowledge, and Skills:</div><ul><li>
Intermediate proficiency level with Microsoft Office Suite</li><li>
Complex problem-solving skills for solving multi-dimensional business questions Proficient in Programming language (i.e., two of SQL, SAS and/or DAX) is required</li><li>
Managed Care Organization knowledge and familiarity</li><li>
Graphic development &amp; presentation skills</li><li>
Exposure to statistical concepts strongly preferred</li><li>
Critical thinking and active listening skills</li><li>
Effective verbal and written communication skills</li><li>
Ability to lead analytic efforts</li><li>
Ability to serve as liaison with business partners</li><li>
Knowledge of managed care and health care data coding</li><li>
Ability to interface with IT teams, familiarity with MDS and advanced data architecture</li></ul><div></div><div>
Licensure and Certification:</div><ul><li>
None</li></ul><div></div><div>
Working Conditions:</div><ul><li>
General office environment; may be required to sit or stand for extended periods of time</li></ul><div></div><div>
Compensation Range:</div>
$70,800.00 - $113,200.00<div>
CareSource takes into consideration a combination of a candidate&rsquo;s education, training, and experience as well as the position&rsquo;s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee&rsquo;s total well-being and offer a substantial and comprehensive total rewards package.</div><div></div><div>
Compensation Type (hourly/salary):</div>
Salary<div></div><div>
Organization Level Competencies</div><ul><li><div>
Fostering a Collaborative Workplace Culture</div></li><li><div>
Cultivate Partnerships</div></li><li><div>
Develop Self and Others</div></li><li><div>
Drive Execution</div></li><li><div>
Influence Others</div></li><li><div>
Pursue Personal Excellence</div></li><li><div>
Understand the Business</div></li></ul><div></div><div><br>
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.</div>
#LI-JM1</div>

Quality Analyst III

CVS Health

<div><p>At CVS Health, we&rsquo;re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.</p><p></p><p>
As the nation&rsquo;s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues &ndash; caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.</p><p></p><p><b>
Position Summary</b></p><p>
This position will be working from home anywhere in the continental US.</p><p>
Standard business hours Monday-Friday.</p><ul><li>
Accountable for conducting oversight of entities that are contracted to perform clinical functions on Aetna's behalf.</li><li>
Monitor and track delegated entities compliance with regulatory and NCQA requirements.</li><li>
Communicate to delegated entities about industry standards, Aetna policies, and best practices.</li><li>
Accountable for preparing delegation oversight resources for NCQA and regulatory reviews</li><li>
This position supports NCQA, CMS, and other regulatory compliance initiatives.</li></ul><p><b><br>
Required Qualifications</b></p><ul><li>
3&ndash;5 years of experience in Quality Management within the healthcare industry</li><li>
Demonstrated ability to consistently meet deadlines in a fast-paced environment</li><li>
Strong communication and interpersonal skills, with a proven ability to collaborate effectively across teams</li></ul><p><b><br>
Preferred Qualifications</b></p><ul><li>
2 to 3 years prior experience working in Commercial/Medicare or Medicaid lines of business</li><li>
Medical Terminology and Claims Experience</li><li>
QuickBase Experience</li><li>
Experience with flexing and shifting priorities</li><li>
Experience working independently and collaboratively to solve problems, make decisions, and complete work/projects</li><li>
Growth mindset (developing yourself and others) skills</li></ul><p><b><br>
Education</b></p><ul><li>
Bachelors Degree Preferred</li></ul><p></p><p><b>
Anticipated Weekly Hours</b></p>
40<p></p><p><b>
Time Type</b></p>
Full time<p></p><p><b>
Pay Range</b></p><p>
The typical pay range for this role is:</p><p></p>
$43,888.00 - $102,081.00<p></p><p>
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.</p><p><br>
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p><p></p><p><b>
Great benefits for great people</b></p><p></p><p>
We take pride in our comprehensive and competitive mix of pay and benefits &ndash; investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:</p><ul><li><p><b>
Affordable medical plan options,</b> a <b>401(k) plan </b>(including matching company contributions), and an <b>employee stock purchase plan</b>.</p></li><li><p><b>
No-cost programs for all colleagues </b>including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</p></li><li><p><b>
Benefit solutions that address the different needs and preferences of our colleagues</b> including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.</p></li></ul><p></p><p>
For more information, visit https://jobs.cvshealth.com/us/en/benefits</p><p></p>
We anticipate the application window for this opening will close on: 11/21/2025<p></p><p>
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p></div>

Analyst, Health Care Quality Management - Work at Home

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4.230_HB ARS Mgmt_Quality Analyst

Quality Analyst III

Analyst, Health Care Quality Management - Work at Home

Analyst, Health Care Quality Management - Work at Home

Analyst, Health Care Quality Management - Work at Home

Analyst, Health Care Quality Management - Work at Home

Analyst, Health Care Quality Management - Work at Home