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Quality Assurance Manager - Operations

Company: CareOregon Inc
Location: Portland
Posted on: February 25, 2021

Job Description:

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 basis.
  • 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 protocols.
  • 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 Acceptance Testing
    • 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 features.
    • 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 appropriate format.
    • Develop and manage the tracking of post-production test results.
    • 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 executive management.
    • 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 activities.
    • Participate in and lead Test Readiness Reviews as necessary. Process Improvement
      • 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 results.
      • Monitor and report on remediation outcomes and process improvement changes to measure the effectiveness of the changes.
      • Develop and maintain QA and UAT related policies, procedures and workflows.
      • 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 goals
        • Work in partnership with various internal departments as well as subcontractors
        • Perform other duties as needed. Management and Leadership
          • Train, supervise and evaluate performance of assigned staff.
          • 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 schedules, etc.)
            • Strong understanding of state and federal regulations that impact operations
            • Comprehensive skills in program development, management and evaluation
            • Strong statistical, analytical and problem-solving skills
            • Ability to determine root problems
            • Ability to create test requirements
            • Ability to recommend new and improved operational processes
            • Strong detail-orientation, prioritization and organization skills
            • Ability to work well under pressure in a complex and rapidly changing environment
            • 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 attitude
            • Excellent spoken, written and presentation communication skills
            • 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 within departments
            • Ability to lead and influence change and results
            • Ability to work effectively with diverse individuals and groups
            • 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 environments
                • 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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