Overview
HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology. Learn more at HealthEdge.com.
Job Summary
The Utilization Management (UM) Quality Assurance Analyst is responsible for supporting quality improvement initiatives by conducting comprehensive audits, analyzing operational processes, identifying trends and opportunities for improvement, and ensuring compliance with utilization management policies and procedures. This role plays a critical part in maintaining the accuracy, consistency, and quality of UM reviews, documentation, and member interactions while supporting operational excellence and regulatory compliance.
The QA Analyst collaborates with leadership and operations teams to evaluate performance, provide actionable insights, develop educational materials, support system implementations, and contribute to continuous process improvement initiatives.
Key Responsibilities
Quality Assurance & Auditing
- Perform quality assurance audits on completed prospective, concurrent, and retrospective utilization management reviews involving inpatient, outpatient, ambulatory, and ancillary services.
- Evaluate accuracy, completeness, timeliness, and compliance of UM documentation and decision-making processes.
- Conduct quality audits of member and provider calls to ensure adherence to policies, procedures, benefit plans, regulatory requirements, and customer service standards.
- Verify the accuracy, consistency, and integrity of operational data and quality reports.
- Identify audit findings, trends, risks, and opportunities for process improvement.
- Auditing the nurses that processes appeals and grievances as well
Analysis & Reporting
- Research, analyze, and evaluate data from multiple sources to identify discrepancies, trends, and potential operational issues.
- Assist in monitoring quality initiatives, outcomes, metrics, and objectives to ensure performance goals are achieved.
- Prepare reports, presentations, and other materials to communicate audit results and recommendations to management.
- Support root cause analysis activities and recommend corrective and preventive actions.
Education & Training
- Provides recommendation related to, but not limited to, the following:
- Utilization Management policies and procedures
- Clinical documentation standards
- Benefit interpretation
- Regulatory and compliance requirements
- Quality improvement initiatives
- Assist in the creation of user guides, training manuals, and process documentation.
Process Improvement & Project Support
- Collaborate with leadership to identify operational challenges and recommend innovative solutions.
- Support change management initiatives by assisting with planning, organizing, and controlling project activities.
- Participate in User Acceptance Testing (UAT), system enhancements, and implementation projects as needed.
- Assist in developing business requirements documentation and workflow improvement recommendations.
- Support process redesign efforts to improve efficiency, accuracy, and quality outcomes.
Collaboration & Stakeholder Support
- Partner with operations teams to validate report content, audit results, and quality findings.
- Maintain effective communication with internal stakeholders and leadership regarding quality trends and performance improvement opportunities.
- Maintain comprehensive knowledge of business operations, products, programs, organizational structure, and utilization management processes.
Additional Responsibilities
- Perform other duties and special projects as assigned.
- Support departmental and organizational objectives through ongoing quality improvement efforts.
Required Qualifications
Education
- 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.
Experience
- Minimum of 2 years of experience in U.S. Healthcare, UM account, quality background great with emphasis on:
- Utilization Management (UM)
- Medical Management Operations
- Care Management or Managed Care environments
Preferred Experience
- Quality Assurance (QA)
- Experience auditing utilization management reviews and clinical documentation.
- Experience in managed care, health plans, or third-party administration environments.
- Experience supporting process improvement or operational quality initiatives.
Preferred Systems Knowledge
- HealthEdge HRCM
- GuidingCare
- JIRA
- Other utilization management platforms and workflow systems
Required Skills, Knowledge, and Abilities (SKA)
- 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
- Outlook
- Ability to independently evaluate data and identify trends, gaps, and opportunities for improvement.
- Ability to work both 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.
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