Sr. Consultant, Quality Control & Improvement

Navitus Health Solutions is seeking a Sr. Quality Improvement Consultant to join our team!

The Sr. Quality Improvement Consultant is an integral part of the Claims Quality Assurance & Testing (QAT) team which performs multiple functions in quality control and quality improvements with a goal to ensure the accuracy of benefit plan configuration in the NavicareRX system for the entire enterprise. They are responsible for ensuring that internal process adherence is met for all lines of business and all departments. This position will be responsible to partner with business partners and implement a work management tool that feeds information to the Claim Adjudication Operations teams. The QAT team reviews the client's requirements at implementation to determine client intent and audit approach to gain the expected outcome. This position will collaborate with the Implementation, Account Management, Compliance, and IT teams. This position will utilize system expertise, client documentation, claim adjudication rules, and QAT team processes and procedures to effectively identify coding errors and identify trends to improve processes.

Is this you? Find out more below!

How do I make an impact on my team?

Executes on assigned Quality Process Improvement projects and quality initiatives, including leading work management project, heat mapping project, and roadmaps
• Ability to organize information, learn complex technologies and explain concepts and instructions clearly and concisely to all levels of employees
• Initiates process improvements, root cause analysis, preventative action implementation, metrics, automation, training, documentation, and compliance
• Works with Quality Leader and business partners to clearly define new client implementation testing processes for the enterprise
• Attends workgroup meetings to improve upstream processes related to requirements and work management tools
• Creates and maintain quality test case templates, workbooks, job aids and provide training for any tools created in this role
• Anticipates customer needs and proactively develops solutions to meet them. Attend client implementation calls representing Quality regarding testing and validation to ease client concerns
• Identifies patterns, trends, and relationship of data to Forecast and plan resource requirements along with Quality Leader. Create and maintain the Quality Team's C2D (Capacity to Demand) which assists with forecasting and participate in client implementation FTE planning
• Authorizes deviations from standards. When working with Health Plan accounts there are many different challenging scenarios, especially in validation. The standard way that works for an account with 10 plans might not work for an account with 29,000 plan codes. You need to be creative and think outside the box to complete the audit efficiently and accurately
• Other duties as assigned

What our team expects from you?

• College degree or work experience equivalent
• 10+ years of relevant work experience in the healthcare industry or demonstrated expertise with benefit configuration and testing
• Expert level experience using MS Excel filtering, sorting, and analyzing data with ability to write complex Excel formulas
• Minimum eight years of experience in leading and implementing process improvement initiatives
• Minimum eight years of experience in the health care industry, or equivalent
• Knowledge and demonstrated experience with usage of industry standard tools for managing projects and quality improvement initiatives
• Experience in creating a heat map and identifying quality gaps for an entire enterprise
• Minimum 8 years' experience in a client facing role with the ability to articulate the PBM process and answer client questions related to quality controls
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees