Provider Quality Assurance Analyst
Current• Identify issues, suspected abusive, and fraudulent activities from a variety of sources; obtain and secure relevant evidence; develop and follow through with an investigative action plan to mitigate exposure to company; and/or assist SIU submit the investigation to law enforcement• Locate provider trends to identify outliers in order to improve providers’ quality and remove providers non-compliant with company policies and applicable state and Federal rules and regulations required under Insurance, Workers Compensation, Labor Laws, and civil and criminal codes. • Oversee MPN Provider Quality Assurance complaint process in order to improve productivity and reduce response time by documenting and tracking concerns and investigative requests, providing updates inclusive of recommendations, and addressing/resolving non-clinical issues• Receive audit requests from SIU, Claims, Medical Management, Bill Review, and Legal personnel; conduct computer investigations including database searches; develop and analyze background information; and report findings back to original requestor• Provide technical guidance, training, oversight, and development of new unit members and interns• Seek opportunities for efficiency and savings by identifying issues during review and investigation process, and escalate potential inappropriate discoveries for further investigation and action to appropriate department(s) such as Billing, Claims, and SIU
