Quality Assurance Manager - Operations
Company: CareOregon Inc
Posted on: February 25, 2021
Career Opportunities: Quality Assurance Manager - Operations
(16224) Position Title: Quality Assurance Manager - Operations
Department: Payment Integrity Title of Manager: Director, Payment
Integrity Supervises: Operational Quality Assurance and UAT Staff
Exemption Status: Exempt Requisition: 16224 General Statement of
Duties The Quality Assurance Manager - Operations guides and
oversees User Acceptance Testing (UAT) and Quality Assurance (QA)
for transaction level processes within Operations across all
CareOregon regions, lines of business and products. The role's
leadership in this capacity spans multiple departments including
Claims, Enrollment, Payment Integrity and Clinical Operations. The
position is responsible for department planning, as well as
developing, implementing and managing internal operations and
vendor transactional QA and UAT processes, reports, dashboards and
workflows to ensure CareOregon's quality standards are achieved and
compliance requirements are met. Additionally, the role is
responsible for communicating results, process improvements and
remediation outcomes both laterally and horizontally. Work is
accomplished in collaboration with business partners to foster and
promote error-free transactional operations processing. Essential
Position Functions Transactional Operations Quality Assurance
- Develop robust Operations QA programs for all CareOregon and
subcontractor transactional processing.
- Develop department metrics and performance standards and
motivate the team in meeting or exceeding them.
- Develop and maintain tracking mechanisms and dashboards to
monitor quality assurance results.
- Identify QA trends and root causes and communicate findings to
appropriate departments, subcontractors and personnel on a regular
- Coordinate with the Payment Integrity department to resolve
overpayment or other adverse trends identified.
- Produce accurate and timely QA reports at the individual, team,
line of business, leader and department level.
- Prepare and coordinate internal quarterly business reviews and
presentations as needed.
- Monitor and ensure the timely completion of QA audits and
resolution to disputes or rebuttals.
- Assess the quality of changes to transactional processing and
their improvement over time.
- Monitor and test high-dollar claims against accuracy
- Stay abreast of regulatory and contractual changes and
communicate the changes to staff.
- Ensure compliance with applicable state, federal and health
plan policies and regulatory requirements. Transactional User
- Manage the work function and team responsible for testing the
accuracy of operations transactional processing for all changes to
operational platforms, software and applications.
- Manage UAT in accordance with approved test plans; review test
results and research unexpected results to validate outcomes.
- Create acceptance criteria that leads to testable
- Develop and manage test data, test cases, user stories,
playbooks, job aids and testing scripts.
- Review and approve all testing documentation before use.
- Schedule Operations' UAT.
- Oversee the documentation of all test results in the
- Develop and manage the tracking of post-production test
- Provide recurring status updates on the status of UAT efforts
for all releases in progress.
- Develop and present weekly status reports to the team and
- Participate in deployments to perform UAT during and after
standard business hours as necessary.
- Participate in scheduled and ad hoc meetings as required.
- Interpret state and federal policies as they relate to testing
- Participate in and lead Test Readiness Reviews as necessary.
- Identify opportunities for improvement and recommend
changes/enhancements to processes, processing guides and/or
internal tools to achieve improved quality outcomes.
- Identify remediation recommendations (e.g. new controls,
changes to systems, supplemental training, new policies and
procedures, enhanced processing guides, etc.) in response to QA
- Monitor and report on remediation outcomes and process
improvement changes to measure the effectiveness of the
- Develop and maintain QA and UAT related policies, procedures
- Develop training documents and conduct process trainings on a
regular basis. Essential Department and Organizational Functions
- Meet deadlines for completion of workload.
- Maintain agreed upon work schedule.
- Demonstrate cooperation and teamwork.
- Provide cross-training on specific job responsibilities.
- Meet identified business goals that contribute to departmental
- Work in partnership with various internal departments as well
- Perform other duties as needed. Management and Leadership
- Train, supervise and evaluate performance of assigned
- Provide staff with the training, mentoring and resources
necessary to carry out their work.
- Ensure adherence to department and organizational standards,
policies and procedures.
- Ensure performance goals, expectations and standards are
clearly understood by supervised staff.
- Evaluate employee performance on an ongoing basis; take
appropriate corrective action if needed.
- Perform human resource functions in collaboration with Human
Resources Knowledge, Skills and Abilities Required
- Knowledge and skill in health plan operational system
management, programs and editing software related to claims,
enrollment and clinical operations transactional processing
- Knowledge of medical terminology
- Working knowledge of claims coding requirements and payment
methodologies (e.g. Prospective Payment System (PPS), Medicare fee
- Strong understanding of state and federal regulations that
- Comprehensive skills in program development, management and
- Strong statistical, analytical and problem-solving skills
- Ability to determine root problems
- Ability to create test requirements
- Ability to recommend new and improved operational
- Strong detail-orientation, prioritization and organization
- Ability to work well under pressure in a complex and rapidly
- Ability to support and comply with organizational policies,
procedures and guidelines
- Knowledge of how to confidently navigate through complex and
challenging business issues
- Self-motivated, adaptable to change and forward-thinking
- Excellent spoken, written and presentation communication
- Excellent interpersonal skills
- Excellent leadership skills including the ability to coach,
mentor and inspire staff working both onsite and remotely
- Skill in negotiation and conflict resolution
- Skill in collaboration and consensus building between and
- Ability to lead and influence change and results
- Ability to work effectively with diverse individuals and
- Ability to maintain positive and professional relationships as
a role model, leader and representative of CareOregon
- Understanding of Agile development principles helpful
- Ability to work in PowerPoint helpful
- Ability to create detailed analytical models using Excel or
other tools helpful
- Knowledge of current vendor products to support testing helpful
Physical Skills and Abilities Lifting/Carrying up to 10 Pounds
Pushing/Pulling up to 0 Pounds Pinching/Retrieving Small Objects
Crouching/Crawling Reaching Shoulder/Neck Movement 0 hours/day 0
hours/day 0 hours/day 0 hours/day 0 hours/day 0 hours/day More than
6 hours/day Standing Walking Reading Hearing Speaking Clearly 0
hours/day 0 hours/day 0 hours/day 0 hours/day More than 6 hours/day
More than 6 hours/day 3-6 hours/day 3-6 hours/day Cognitive and
Other Skills and Abilities Ability to focus on and comprehend
information, learn new skills and abilities, assess a situation and
seek or determine appropriate resolution, accept managerial
direction and feedback, and tolerate and manage stress. Education
and/or Experience Required:
- Minimum 5 years' management or supervisory experience in health
care operations, quality assurance, audit and/or UAT in a health
plan setting; experience should include management or supervision
of remote and production-driven, multidisciplinary teams
- Minimum 5 years' experience in claims processing, enrollment
and/or clinical authorization operations
- Experience developing quality and testing programs, processes
and procedures from the ground up
- Experience translating business and system requirements into
test plans, test cases, and traceability matrices Preferred:
- Experience performing statistical claims analysis in a managed
care or health care setting
- Clinical coding certification(s) (e.g. Certified Professional
Coder (CPC), Certified Coding Specialist (CCS), Certified Medical
Coder (CMC), Certified Coding Associate (CCA), etc.)
- Experience with business intelligence tools (e.g. Tableau)
and/or data frameworks
- Experience in eligibility systems for state health and human
services organizations such as Medicaid, SNAP, TANF
- Testing certification such as Certified Test Manager or above
by the International Software Testing Qualifications Board (ISTQB)
or equivalent from another body
- Experience with applications and front and back end system
testing & technologies in multiple operating systems and
- Experience with the Software Development Life Cycle (SDLC)
using Agile methodology
- Experience directing vendor testing Working Conditions
- Environment: This position's primary responsibilities typically
take place in the following environment(s) (check all that apply on
a regular basis):
- Travel: This position may include occasional required or
optional travel outside of the workplace, in which the employee's
personal vehicle, local transit, or other means of transportation
may be used.
- Equipment: General office equipment and mobile technology
Candidates of color are strongly encouraged to apply. CareOregon is
committed to building a linguistically and culturally diverse and
inclusive work environment Veterans are strongly encouraged to
apply.-- Equal opportunity employer. This company considers all
candidates regardless of race, color, religion, sex, sexual
orientation, gender identity, national origin, disability or
veteran status. --
Keywords: CareOregon Inc, Portland , Quality Assurance Manager - Operations, Executive , Portland, Oregon
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