"Quality Improvement Analyst"

Overview

In 1971, Yale University established Yale Health to provide health services to its faculty, staff and students through a multidisciplinary health maintenance organization located on campus. Yale Health has more than 49,000 members including students, staff, faculty and their families who come from every state in the country and almost every country in the world.

Our state-of-the-art facility at 55 Lock Street, is where our members receive most of their care from our 150+ providers. It is a 144,000 square foot medical facility with over 90 exam rooms, an Acute Care Department, a 15-bed inpatient facility with two negative pressure rooms, a diagnostic imaging suite including MR and CT scan, x-ray and ultrasound and a full-service retail pharmacy.

Yale Health is seeking a Quality Improvement Analyst who will collaborate with operational leaders to ensure accurate claims processing and network compliance. This is a remote role. The Quality Improvement Analyst promotes quality claims management by collaborating with other leaders to detect improvement opportunities and implement corrective actions.

This is a 2-year Fixed Duration, remote position

Schedule: Full-Time - 37.5 HRS, Monday - Friday, 8:30 a.m. - 5:00 p.m. EST. Occasional evenings, weekends or holidays/recess may also be required.

Required Skills and Abilities

1. Working knowledge of medical terminologies and coding, proven experience in a claim's environment, and understanding of HIPAA Confidentiality laws.
2. Excellent written and oral communication, interpersonal, and negotiation skills with a demonstrated ability to prioritize tasks as required. Demonstrated problem-solving/analysis skills.
3. Proven experience building and running SQL queries. Demonstrated experience with Microsoft Office (Word, Excel, Outlook, and PowerPoint).
4. Strong analytical aptitudes, communication, and comprehension capabilities.
5. Enthusiastic attitude, cooperative team player and demonstrated ability to adapt to new or changing circumstances.

Principal Responsibilities

1. Audit system configuration against provider contract requirements.
2. Identify fee schedule, provider rate, and benefit setup discrepancies.
3. Collaborate with IT and operations to resolve claims configuration gaps.
4. Perform routine and complex audits of claim transactions processed within our Production a to validate results and communicate exceptions.
5. Detailed review of internal and external reporting.
6. Support quarterly claim audits and updates.
7. Assess the impact of configuration changes by processing claim adjustments, manual claim entry, void-reissue of payment, etc.
8. Support new claims adjudication by validating benefits and claims logic were loaded correctly.
9. Develop and prepare reporting results of findings from process audits and testing.
10. Assisting in identifying the root cause of errors inline to system configuration vs manual processing.
11. Assist in drafting reimbursement policies.
12. Support network assessment and gap identification.
13. Help identify solutions for system issues impacting claim processing results.
14. Provide audit feedback to the claim's leadership team when a need for group and/or individual training has been identified.
15. Perform focus audits, create ad hoc reports and summarize results for management and/or client.
16. Perform other duties as assigned in support of effective, efficient operations related to provider contracting and reimbursement.

Required Education and Experience

Bachelor’s degree and a minimum of 5 years of advanced claims adjudication experience including facility, professional and ancillary claims; and a minimum of 3 year’s experience auditing of claims adjudication.