Quality Management Specialist

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    "description": "<p><strong>JOB SUMMARY </strong></p>\n\n<p><span style=\"color:#000000;\">Evaluate and enforce policies and procedures to maintain the quality of claims documented in Outcomes programs, collaborate with internal stakeholders to identify and outline quality standards as they relate to projects and processes that pose potential risk for quality related issues or fraud, waste and abuse (FWA). Analyze data, reports, operating practices, and documentation as part of the standard monthly claims close and internal auditing processes to ensure quality in business processes.</span></p>\n\n<p><strong>ESSENTIAL DUTIES &amp; RESPONSIBILITIES</strong></p>\n\n<ul>\n\t<li>Demonstrate in-depth understanding of the business model, claim submission requirements and claim validation specifications</li>\n\t<li>Develop and manage an inventory of quality assurance system edits and coordinate with other departments to adjust, as needed</li>\n\t<li>Identify and resolve MTM activity issues and complete fraud, waste, and abuse monitoring by analyzing data, reports, operating practices, and documentation as part of standard monthly claims close and internal auditing processes to ensure compliance</li>\n\t<li>Develop and maintain network educational materials related to policies, procedures, and documentation requirements, including the policy and procedure guide</li>\n\t<li>Coordinate across departments to develop responses to client quality audits</li>\n\t<li>Strategize, execute, and monitor corrective action plans for quality related incidents</li>\n\t<li>Review daily data quality reports, identify inconsistencies and opportunities for improvement</li>\n\t<li>Provide quality assurance support across the business including reporting, processes and other areas as assigned</li>\n</ul>",
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