Virginia Premier Health Plan Quality and Integrity Analyst III in Glen Allen, Virginia

About Us

Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.

By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.

At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.

If this sounds like you, read on!

Overview

The Quality & Integrity Analyst position is responsible for the Quality Assurance (QA) review of system configuration changes made to VPHP’s claims processing systems; focused audit reviews targeting inappropriate payments, and pre-payment claims audits. The Quality & Integrity Analyst plays a key role in identifying, reviewing, and documenting all results related to the QA review of these processes.

The analyst will develop a working knowledge of the program requirements, system configuration of business rules, provider contracts and fee schedules, and all related claims payment data which support coverage of services.

Responsibilities

  • Review system configuration changes documented in VPHP’s change management system

  • Work with system management analysts and QDT analysts to clarify system configuration changes

  • Perform data analysis to identify and validate system configuration changes made to the claims processing platform as well as changes made to the ancillary claims systems (CES and 3M)

  • Perform data analysis of focused audits and pre-payment audits to validate appropriate reimbursements and/or claims processing procedures

  • Document, track and report all QA review results

  • Develop standard and ad-hoc QA reports for management review

  • Develop a thorough understanding of the claims processing systems (IDX MCA, QNXT CES, 3M), as well as a basic understanding of interfacing systems and processes such as EDI, Encounters, Payment Integrity,etc.

  • Identify and document areas of process improvement, including but not limited to, the systems configuration life cycle, the change management process, pre-implementation testing and post-implementation validation

  • Document key business decisions and processes through process workflows

  • Provide training to staff as needed

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • Bachelors Degree in Computer Science, Information Systems, Business or related technical field.

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Advanced knowledge of SQL Server queries to include complex table joins and database functions (average, count, max, min, etc.)

  • Intermediate to Advanced knowledge of DBMS queries and table structures

  • Intermediate to Advanced knowledge of SQL Server Reporting Services (SSRS)

  • Intermediate to Advanced knowledge of SQL Server Integration Services (SSIS)

  • Proficient knowledge of Microsoft Excel to include the use of functions, formulas, pivot tables and macros

  • Thorough understanding of systems development life cycle and change management processes

  • Proficient knowledge of flow charting/process mapping

WORK BACKGROUND/EXPERIENCE

  • Three or more years business experience including Claims or Healthcare related field

  • Three or more years’ experience of software testing and QA validation

  • One or more years leadership experience such as team lead, sponsor, or SME

  • One or more years Project Management experience

  • Proficient understanding of the claims systems configuration life cycle and change management process

  • Proficient knowledge of claims related data structures in SQL Server data warehouse

  • Proficient knowledge of claims related data structures in the claims payment system

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

Our mission is to inspire healthy living within the communities we serve!

Job ID 2018-5336

As an equal opportunity employer, Virginia Premier is committed to a diverse workforce. To ensure non-discrimination and affirmative action for individuals protected by Executive Order 11246, as amended, Section 503 of the Rehabilitation Act of 1973, as amended, the Vietnam Veterans’ Readjustment Act of 1974, as amended, and Title I of the Americans with Disabilities Act of 1990, as amended, Virginia Premier will consider applicants for employment without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. Applicants who require accommodation in the job application process may contact Recruitment at 804-819-5151 for assistance. It is the policy of Virginia Premier Health Plan, Inc., to comply with the requirements of the Drug-Free Workplace Act of 1988. It is a violation of our drug-free workplace policy to use, possess, sell, trade, and/or offer for sale alcohol, illegal drugs or intoxicants in our workplace. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. Virginia Premier participates in E-verify.