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Business System Quality Assurance Analyst

Company: EmblemHealth
Location: New York
Posted on: August 3, 2020

Job Description:

Provides operational and Claims System analysis regarding Quality Assurance in Claims Systems Configuration. This position is created in part from a recommendation by McKinsey to support the Health Cost Containment Initiatives where it is believed that quality improvements will significantly reduce the Enterprises medical expense ratio. The duties include but not limited to the in-depth analysis and validation of various master reference files such as Facility and/or Professional Contracts, Medical Policies, Preauthorization and Referral tables, and Benefit file setups; and the global interrelationships of these files. The incumbent analyst will be responsible for developing and executing quality measurements and reporting, as well as, the review of business requirements that impact reference file interaction. The responsibilities also include the creation of regularly generated audit reports detailing various findings, root cause analysis and documenting pertinent issue resolution and interdepartmental impact; including but not limited to QA efforts pertaining to existing SOX guidelines and protocols.Responsibilities:Performs in-depth quality analysis and validation of the various master reference files, and the processes that use them. This includes Professional and Facility Contracts, Medical Policies, Preauthorization/Referral files, Benefit configurations and CPF facility records.Ensures the review of all system auditing is well documented according to departmental and SOX guidelines, and resides in a Central Repository; and that audit findings are published in a timely manner and that they include root cause evaluation and system resolution.Works closely with QA units, Business Partners, trainers and Contract Managers in all areas that impact reference files and the master file data entry; and may assist in the scheduling and auditing of implementations/releases and risk assessments.Interacts with the Requirement Analysts, Managers, Assistant Directors and Directors throughout the Enterprise in the review of business requirements, design documents and test plans that impact reference files.Participates in the post implementation phase including the validation of production turnover and monitoring of performance as it applies to the reference files.Regular attendance is an essential function of the job. Performs other duties as assigned or required. Qualifications:College Associates Degree (BA/BS preferred)Minimum of 3-5 years'' experience in a QA Analyst role or equivalent; in Health Care Claims QA a plus; requiredExtensive knowledge in Claims Systems Processes, Functionality and File dependencies requiredClear understanding of the purpose, design, construction and maintenance regarding system configuration and accuracy requiredProficient knowledge of contracts, benefits and pricing modules requiredProficient knowledge of ICD9, CPT, HCPCS and DRG coding requiredStrong exposure to formalized testing strategy and detailed auditing principles and techniques requiredStrong knowledge of MS Office tools requiredLean Six Sigma or Green Belt certification a plus; preferred Additional Information Requisition ID: 200H4 EEOC Statement We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law. Sponsorship Statement Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions. by Jobble

Keywords: EmblemHealth, New York , Business System Quality Assurance Analyst, Professions , New York, New York

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