Utilization Management Quality Assurance Analyst
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Job Description
HealthEdge UM QA Analyst auditing utilization reviews, documentation, calls, and appeals. Supporting healthcare quality improvement, reporting, training, and regulatory compliance.
Responsibilities:
- Perform quality assurance audits on completed prospective, concurrent, and retrospective utilization management reviews involving inpatient, outpatient, ambulatory, and ancillary services
- Evaluate the accuracy, completeness, timeliness, and compliance of UM documentation and decision-making processes
- Conduct quality audits of member and provider calls for adherence to policies, procedures, benefit plans, regulatory requirements, and customer service standards
- Audit nurses processing appeals and grievances
- Verify the accuracy, consistency, and integrity of operational data and quality reports
- Identify audit findings, trends, risks, and process-improvement opportunities
- Research, analyze, and evaluate data from multiple sources to identify discrepancies, trends, and operational issues
- Monitor quality initiatives, outcomes, metrics, and objectives
- Prepare reports, presentations, and materials communicating audit results and recommendations to management
- Support root cause analysis and recommend corrective and preventive actions
- Provide recommendations on UM policies and procedures, clinical documentation standards, benefit interpretation, regulatory and compliance requirements, and quality improvement initiatives
- Assist in creating user guides, training manuals, and process documentation
- Collaborate with leadership to identify operational challenges and recommend solutions
- Support change management and project activities
- Participate in User Acceptance Testing (UAT), system enhancements, and implementation projects
- Assist with business requirements documentation and workflow improvement recommendations
- Support process redesign to improve efficiency, accuracy, and quality outcomes
- Partner with operations teams to validate report content, audit results, and quality findings
- Communicate quality trends and performance-improvement opportunities to internal stakeholders and leadership
- Maintain comprehensive knowledge of business operations, products, programs, organizational structure, and UM processes
- Perform other duties and special projects as assigned
Requirements:
- Bachelor's degree in Healthcare Administration, Nursing, Business Administration, Health Information Management, or related field preferred
- Equivalent combination of education and experience may be considered
- Minimum of 2 years of experience in U.S. Healthcare, UM account, quality background, with emphasis on Utilization Management (UM), Medical Management Operations, or Care Management/Managed Care environments
- USRN License
- Strong analytical and problem-solving capabilities
- Excellent verbal and written communication skills, with the ability to communicate complex concepts clearly
- Strong organizational and planning skills, with the ability to manage multiple priorities
- High attention to detail and commitment to accuracy
- Advanced proficiency in Microsoft Office applications, including Excel, Word, PowerPoint, and Outlook
- Ability to independently evaluate data and identify trends, gaps, and opportunities for improvement
- Ability to work independently and collaboratively in a team environment
- Strong interpersonal skills and ability to interact effectively with employees, leaders, and clients at all organizational levels
- Flexibility and adaptability in a fast-paced and changing environment
- Ability to create and maintain business requirements documents, training materials, and procedural guides
- Understanding of quality assurance methodologies, audit principles, and continuous improvement practices
- Knowledge of utilization management workflows, healthcare benefits, and regulatory requirements
- Preferred: Quality Assurance (QA), auditing utilization management reviews and clinical documentation, managed care/health plan/third-party administration environments, process improvement or operational quality initiatives
- Preferred systems knowledge: HealthEdge HRCM, GuidingCare, JIRA, and other utilization management platforms and workflow systems
Benefits:
- Full-Time position
- Personalized site features mentioned, but no job-specific benefits or compensation extras are stated
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