Senior Analyst
The Judge Group Inc.
Job Info
Location: REMOTE
Salary: $40.00 USD Hourly - $50.00 USD Hourly
Description:
Job Title: Senior Analyst
Work Location: Remote
Duration: Contract
Responsibilities:
- Oversee end-to-end business process activities, focusing on creating, controlling, and improving performance guarantee processes related to Prior Authorization (PA) and Appeals.
- Lead process design and project implementation teams to ensure program compliance and quality control, adhering to audit requirements for 19 states serviced by UHC Community and State.
- Identify process improvement opportunities and develop solutions using principles of process excellence and related tools.
- Conduct quality reporting, analysis, and audits, and develop plans and programs to support continuous quality improvement.
- Assist in the creation, implementation, and evaluation of Total Quality Management (TQM) programs related to PA and Appeal performance guarantees.
- Direct the design, facilitation, training, and evaluation of TQM incentive programs and oversee quality improvement projects and teams.
Prior Authorization Governance and Auditing Group:
- Provide audit and regulatory support related to PA and Appeals for all OptumRx clients.
- Serve as the regulatory subject matter expert during oversight and delegation audits performed by various clients.
- Analyze and report Out of Compliance (OOC) data, perform clinical reviews on DOI inquiries to ensure alignment with regulatory guidance.
- Lead data validation efforts for PA and Appeals, ensuring quality control for adherence to accreditation, state, and federal program requirements.
- Conduct clinical validation, reviewing prior authorization cases for clinical decision-making based on individual plan formulary requirements and patient demographics.
- Ensure compliance with various regulations based on lines of business and plan design.
- Identify process improvements to ensure compliance with state and federal laws, business contract requirements, and maintain client relations.
- Analyze and investigate root causes of non-compliant cases.
This job and many more are available through The Judge Group. Find us on the web at www.judge.com
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