Quality Control Reviewer, Medicare, Hybrid
AllWays Health Partners

Somerville, Massachusetts

For over 30 years, AllWays Health Partners has delivered value to our members and worked to improve access to care and coverage. As a member of Mass General Brigham, AllWays is a health plan at the forefront of innovation, advancing a highly integrated model of value-based care with one of the world's leading health care systems. Together, we are transforming the customer experience, keeping our members and patients at the center of everything we do. Bring your unique talents and join us as we strive to create a world where all people live healthier lives.

Under the direction of the Manager, Claims Operations the Claims Quality Control Reviewer will be responsible for monitoring Quality Control (QC) of Claims Operations and the reporting of all metrics related to such activities. This person is responsible for user acceptance testing for project implementation, system implementation, process implementation, program implementation, and post-implementation QC. This person must have the ability to use an unbiased and objective point of view for each audit performed.

The Quality Control Reviewer will perform trend analysis and root cause review analysis. The person in this role will be responsible for identifying potential areas of compliance vulnerability and risk, and working with department supervisors/managers to develop and implement corrective action plans as needed and recommend appropriate solutions to enhance current quality assurance programs. This person must have the ability to apply an end-to-end process orientation to their work to anticipate risks that impact AllWays Health Partners' financial strength, quality, compliance or customer experience. This person will proactively partner with business units to eliminate or minimize such risks. Using excellent collaboration skills this person will work with the various departments throughout Allways Health Partners to include, Claim Operations, Provider Network Management, Clinical Services, Provider Relations, Benefits Administration, Reimbursement Strategies, Contracting, and others throughout the organization to improve end to end processing.

In this role, this person will develop and implement new quality control processes, assist in the business testing process, and participate in projects.

Essential Functions
• Manage QC audit programs, perform testing, evaluate and compile results
• Conduct operational audits as well as compliance audits within Claims Operations
• Track and report appropriate QC metrics
• Conduct root cause analysis to identify trends and knowledge gaps as part of issue resolution
• Analyze QC scores to determine trends and identify training needs and opportunities for improvement
• Anticipates and meets, or exceeds, internal and/or external customer expectations and requirements; establishes and maintains effective relationships with customers and gains their trust and respect.
• Hold self and others accountable to meet commitments.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate AllWays Health Partners as a people-first organization.
• Provide clarification to policies and procedures as needed and respond to and implement new policies and programs.
• Align business requirements documents, provider payment guidelines, and desktop procedures.
• Responsible for keeping up to date on all Allways Health Partners benefit changes and authorization rules working with the operations documentation specialist to ensure policies and procedures are updated.
• Other duties as assigned with or without accommodation.

Working Conditions and Physical Effort
• Work is normally performed in a remote or office work environment.

Knowledge and Education

• Bachelor's Degree or the equivalent combination of training and experience


• 5 years in healthcare
• 3 or more years experience in monitoring, measuring and reporting on quality and productivity
• Must have strong knowledge of claims processing and ICD-10, HCPCS and Revenue Codes and billing practices.

• Experience working as part of a remote team
• 1+ years in a team lead or supervisory role


• Experience developing quality programs preferred
• Strong knowledge of Medicare/Medicare Advantage and Medicaid rules and regulations
• Knowledge of Centers for Medicare & Medicaid Services Center (CMS)
• Intermediate/advanced excel skills
• Abiliity to maintain confidentiality
• Excellent customer service skills
• Excellent written and oral communication skills, presentations, facilitation, operational and consultation skills
• Strong time management skills and self-discipline when working remote
• Demonstrated ability to work with all levels of the organization
• Ability to work and operate independently or as part of a team
• Demonstrate AllWays Health Partners' core brand principles of always listening, challenging conventions, and providing value
• Strong aptitude for technology-based solutions.
• Ability to inject energy, when and where it's needed.
• Respect the talent and unique contribution of every individual, and treat all people in a fair and equitable manner.
• Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback.
• Be accountable for delivering high-quality work. Act with a clear sense of ownership.
• Bring fresh ideas forward by actively listening to and working with employees and the people we serve.

Organizational Relationships/Scope
• Will report to the Manager of Claims Operations
• Will interact and partner with Claims Management within the Claims Operations department
• Maintain excellent relationships within other AllWays Health Partners departments
• Some contact with intermediaries

EEO Statement
Our promise as a people-first organization starts with our employees. AllWays Health Partners is committed to diversity, equity, and inclusion in our workforce, internal culture, and investments. As an equal opportunity employer, AllWays Health Partners recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives, and backgrounds.

The above statements are intended to describe the general nature and complexity of the work being performed by personnel assigned to this classification and do not represent an exhaustive list of all tasks, duties, and responsibilities required of personnel assigned to this position.

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