Quality Assurance Specialist

Quality Assurance Specialist

This position is a member of the Quality and Compliance team to ensure adherence to regulatory requirements, company policy and protocols and achievement of quality standards. Responsible for conducting audits of medical records, coding, utilization, and billing patterns to ensure the services performed and clinical information within the medical record is accurate, appropriate, complete, and compliant. Reports to the Senior Director of Corporate Operations, Quality Assurance and Compliance.

Education : High school diploma or equivalent required. Bachelors degree in Healthcare Administration, Business Administration, Organizational leadership or related field preferred.

Experience : 3 years of experience in healthcare quality assurance, utilization management, risk management, compliance, or related experience. Experience in behavioral health is a plus.

Licenses / Certifications : Fellowship of the American College of Healthcare Executives(FACHE), Certified Healthcare Financial Professional (CHFP), Certified Professional in Healthcare Risk Management (CPHRM) or related certification is preferred.

Responsibilities :

Utilization Reviews :

• Analyzing patient records to assess the need for and appropriateness of medical treatments.
• Checking if treatment plans adhere to Deer Oaks' utilization review guidelines and insurance policies.

Reporting, Analyzing and Evaluating Data :

Conducting Audits and Reviews :

Assists with compiling medical records and clinical summaries for external record reviews and audits from insurance companies and regulatory agencies.

Maintains tracking tools to log audits conducted, findings and recommendations.

Based on data analysis and documentation reviews, identifies and clearly communicates (verbally and in written reports or summaries) potential quality of care and service issues for further action.

Supports other Quality Improvement efforts as needed. Collaborates with the QA and Compliance Leadership Team to develop and implement programs for ongoing quality and clinical documentation improvements.

Assists with creating and revising audit tools and quality reporting, as necessary, to ensure audits and reports are value added for senior and executive management.

Participates in special projects collecting, analyzing and summarizing data utilizing Excel and prepares professional reports to communicate findings and recommendations to QA and Compliance Leadership Team.

Contributes creative solutions and ownership of daily assignments for seamless communication and systematic completion of routine and special projects.

Other duties as assigned to support the company's mission.

Required Skills / Experience / Abilities :