Senior Analyst(s) will be responsible for end-to-end business process activities - creating, controlling and improving the performance guarantee processes related to Prior Authorization and Appeals.
Will lead process design and project implementation teams to assure program compliance and quality control for adherence to audit requirements based on governing bodies for the 19 states serviced
Responsible for diagnosing process improvement opportunities and developing solutions using principles of process excellence and related tools.
This position is also responsible for quality reporting, analysis, audits and for developing plans and programs to support continuous quality improvement using applicable tools.
May assist in the creation, implementation, and evaluation of Total Quality Management (TQM) programs surrounding PA and Appeal related performance guarantees.
May direct design, facilitation, training and evaluation of TQM incentive programs and may oversee quality improvement projects and teams in functional area.
The Prior Authorization Governance and Auditing Group provides audit and regulatory support related to Prior Authorization and Appeals for all clients .
The analyst(s) will serve as the regulatory subject matter expert during oversight and delegation audits performed by various clients.
Analyst(s) will be responsible to analyze and report OOC data, perform clinical review on all DOI inquiries to ensure the PA and appeal process are aligned with regulatory guidance.
Analyst(s) will lead data validation efforts for PA and Appeals including quality control for adherence to accreditation, state and federal program requirements.
Clinical validation includes review of prior authorization cases for clinical decision-making based on individual plan formulary and requirement and patient demographics.
The analyst(s) will ensure compliance to various regulations based on lines of business and plan design.
In addition to audit support, the analyst(s) will be involved with trending to identify process improvements to ensure compliance with applicable state and federal laws, business contract requirements, prevent untimely cases and maintain client relations.
Analyzes and investigates root cause of non-compliant cases.
