Job Details

Summary of Job

Proactively assess and monitor vendor Provider File Operations performance to achieve contractual targets on a daily basis. Frequently interface with Provider Operations Tower Leaders to continuously identify and communicate opportunities for improvement within Provider File Operations and business partner (claims, customer service, benefit set-up, enrollment, and medical and pharmacy) core processes. Identify areas of improvements in Provider File Operations, provide appropriate action plans, develop and implement Vendor Operations performance analysis programs and metrics to improve operational efficiency. Enhance brand and customer experience by identifying opportunities for improvement and variation trends via proactive
assessment.

Responsibilities

• Create and execute test cases to deliver optimal system functionality and ensures that changes meet business and quality requirements.
• Report program incident trends; provide recommendations to resolve identified gaps in processes or protocols; work with the teams to create corrective action plans and provide oversight for implementation and impact assessment.
• Participate in the development and implementation of efficient and effective QA methodology, including test automation, processes, procedures, templates, guidelines, and tools.
• Conduct assessments and evaluate strategies to elevate overall quality and performance, as necessary.
• Monitor and support programs on the utilization of best practices based on data collection and insight from various QA/QI standards, in partnership with the City, State, Federal, or other regulatory bodies
• Plan, execute, and provide oversight of multiple and simultaneous team-based projects along with other individually assigned projects, including providing support in developing and expanding the scope of the company's corporate dashboards and other management reports for distribution to middle and upper management.
• Organize and maintain report methodology documentation.
• Continuously develop more efficient ways to produce reports; conceptualize approaches; advance skills of staff.
• Develop visual platforms to share data, best practice highlights, and other information pertaining to program QA.
• Communicate and collaborate with other Vendor Operations Management stakeholders as needed to support overall EmblemHealth quality and customer experience objectives. Feed opportunities to your respective Vendor Operations Tower Leaders on a real time basis to ensure proper and timely escalation to accountable parties.
• Regular attendance is an essential function of the job. Perform other duties as assigned or required

• Bachelor's Degree, preferably in a quantitative analysis or related field
• Lean Six Sigma or Green Belt certification (Preferred)
• 3 - 5+ years of relevant, professional work experience (Required)
• 2+ years' QA analysis experience, preferably in healthcare (Required)
• Clear understanding of the purpose, design, construction and maintenance regarding system configuration and accuracy (Required)
• Proficient with MS Office tools, SQL (Oracle or SQL Server); experience working with large volumes of data (Required)
• Knowledge of CPT/ICD 9 & 10 Codes, Diagnosis Codes, Revenue Codes (Required)
• Business Intelligence Experience - Cognos or Tableau (Preferred)
• Energy, drive and passion for End-to-End excellence and customer experience improvement (Required)
• Excellent collaboration skills and the ability to influence management decisions (Required)
• Strong problem solving and analytical skills that can be applied across all types of business problems (Required)
• Excellent communication skills - verbal, written, interpersonal, presentation, collaboration, facilitation (Required)
• Solid coaching skills to continuously develop staff core data analysis competencies at vendors (Required)
• Strong exposure to formalized testing strategy and detailed auditing principles and techniques (Required)