Quality Assurance Reviewer (Independent Dispute Resolution Entity)

Position Description: Quality Assurance Reviewer (Independent Dispute Resolution Entity)

Under the direction of the Independent Dispute Resolution Entity (IDRE) Project Manager or his/her designee, the Quality Assurance Reviewer [Independent Dispute Resolution Entity (IDRE)] evaluates the assessments, decisions and outcome determinations rendered by the Insurance Specialists (Eligibility) and Health Insurance Specialists to assure that the appropriate standards have been applied and criteria have been met for IDR case acceptance, processing and payment adjudication. They will review the timeliness, accuracy and quality of case-specific assessment, documentation and communications related to specific steps in the IDR process including but not limited to: request intake, acceptance and initiation of IDR process and payment determination prior to submission to the client, checking for accuracy and completeness. They will evaluate/score reviewers both for production/quantity and precision/quality. In times of peak volume they will also undertake IDRE reviews and act as either a Health Insurance Specialist or an Insurance Specialist (Eligibility).

Responsibilities:

• Understand and represent PRI's mission, vision, and values to all internal and external customers
• Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI management
• Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
• Adheres to a detailed project schedule to ensure compliance with
• Proactively manages and coordinates activities to ensure timeliness of deliverables to exceed contractual obligations
• Interact with project team members in order to successfully fulfill contract obligations with the highest quality and in a timely manner meeting PRITM's ISO requirements
• Instills integrity throughout the organization via active participation in ISO requirements including but not limited to timely submission of Corrective Action Plans for all matters in which either PRITM standards and/or corporate contract standards have not been met. Communicating outcomes to team members to ensure a positive, open, environment which mitigates risk and achieves a culture of Continuous Quality Improvement.
• Contributes to business development efforts for new sales and marketing to promote the business through QA initiatives, professional communications, sound decisions and by exceeding all contract timeframes and deliverable requirements,
• Ability to measure and evaluate the output of IDRE Insurance Specialists (Eligibility) and Health Insurance Specialists and consistently apply appropriate measures
• Report any errors found and recommend corrective measures
• Utilize program and government resources for research and reference verification
• Demonstrated skill and experience in managing a large workload with varying deliverable dates
• Flexible with assignments to meet contract performance metrics
• Participate in interdisciplinary collaboration with PRI staff, recognized teaming partners, and/or subcontractors
• Demonstrated skill and experience in the submission of timely, accurate deliverables
• Demonstrated experience and skills in excellent customer service
• Proven skill and experience in excellent oral and written communication spanning executives to the general public
• Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI
• Perform Quality Assurance review and reporting activities to ensure contract metrics are met
• Performs Independent Dispute Resolution review and payment adjudication activities when needed
• Perform other duties as requested