Senior Provider Quality Auditor

Support leadership with the coordination, implementation, and oversight of all facets of the Quality Management Program. Facilitate medical record audits, research complaints related to potential quality issues, analyze quality trends, and maintain thorough documentation of quality audits and investigations. Apply knowledge of healthcare quality standards to objectively and systematically assess provider adherence to established quality objectives and goals. Promote a culture of quality, excellence, and continuous improvement.

Effectively communicate with physicians and other healthcare staff to ensure accurate, complete, and timely medical record documentation is received for quality assurance reviews

Complete quality assurance reviews according to established audit schedules and procedures

Obtain and review patient medical records in preparation for audit review by physician leadership and clinical reviewers

Partner with clinical reviewers to educate contracted doctors and ensure compliance with appropriate standards of care, including facilitating the implementation of corrective action plans, when necessary

Actively participate in quality investigations and the development/implementation of corrective action plans

Inform Quality Management leadership of concerns related to corrective action plans

Maintain a working knowledge of current clinical guidelines that affect quality assurance reviews and investigations

Analyze audit findings to identify trends in non-compliance and present results to leadership and the Quality Management Committee

Work with contracted partners to investigate and effectively resolve found quality of care and quality of service issues within established timeframes

Collaborate with clinical reviewers to identify quality of care concerns and communicate corrective action plans to contracted doctors

Escalate significant, recurring, or systemic quality concerns for further review and interventions

Support the effective operations of the Quality Management Committee by preparing and presenting accurate reports, quality improvement work plans, interrater studies, and maintaining meeting records to ensure compliance with organizational and regulatory standards

Research, analyze, and resolve complex issues and escalations related to medical record reviews, member complaints and grievances, and quality of care issues

Lead end-to-end preparation and facilitation of quality assurance activities for client, regulatory, and accreditation surveys, including research audit documentation, and support of corrective action plans

Maintain proper documentation of records, reports, audit findings, and corrective action plans in a manner that will allow data to be categorized, tracked, trended for analytics, and audited by clients, regulatory, and accreditation agencies

Interpret and monitor quality assurance metrics to identify compliance with established quality goals, standards, and benchmarks

Develop, implement, and distribute quality management policies, procedures, documents, and training materials in accordance with company standards, quality agencies, state and federal laws and regulations, and governing optometric associations’ guidelines

Other duties as assigned to promote and maintain quality within the company

Job Specifications

Typically has the following skills or abilities:

Bachelor’s degree in Business Administration, Healthcare Administration, Public Health, or other quality management-related field, or equivalent experience

Minimum of four (4) years of quality assurance experience

Strong knowledge of provider relations, quality management systems, and quality improvement processes preferred

Excellent written, verbal, and interpersonal communication skills

Ability to handle sensitive information with the highest degree of integrity, discretion, and confidentiality

Self-motivated with the ability to prioritize and complete multiple complex work assignments independently and across a fast-paced team environment

Highly analytical, with a knack for identifying trends, drawing conclusions, and communicating results

Ability to learn complex processes, medical terminology, application systems, and identify effective business solutions through research, audit, and analysis

Commitment to continuous process improvement

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Compensation range for the role is listed below. Applicable salary ranges may differ across markets. Actual pay will be determine