Virginia Premier Health Plan Quality & Integrity Analyst II 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, editing and pricing systems. The Quality & Integrity Analyst plays a key role in identifying, reviewing, and documenting all results related to the QA review of these system changes. In addition, the analyst will perform pre /post payment random and focus audits.

The analyst will develop a working knowledge of the system configuration of business rules that support coverage of services, as well as the system configuration of contracts and fee schedules that support reimbursement.

Responsibilities

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

  • Work with claims systems configuration analysts to clarify system configuration changes

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

  • 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, editing and pricing systems, as well as a basic understanding of interfacing systems and processes such as EDI, Trapeze, 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

Qualifications

MINIMUM EDUCATION REQUIREMENTS

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

SPECIAL KNOWLEDGE AND/OR SKILLS

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

  • Working knowledge of SQL Server Reporting Services (SSRS)

  • Working 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

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

  • Two or more years’ experience of Claims related system testing and QA validation

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 2018-5337

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.