Company Overview
CSTS Customer Service and Technology Solutions LLC is a dedicated third-party administrator specializing in managing the administrative and operational functions for insurance plans. Our mission is to revolutionize the healthcare experience by delivering exceptional products and services to our partners, ensuring compliance and efficiency at every step.
Position Overview
CSTS is looking for a Data Analyst to ensure internal and external quality standards are met through internal and external auditing and monitoring according to CMS and NCQA Standards. Develop and maintain a quality data base and quality monitoring tools. Develop a training data base and training tools. Design and implement a formal quality improvement process. Lead monitoring oversight for the internal UM team and External Vendors performing UM functions. Conduct monthly individual user audits for the UM team and quarterly audits of External Vendors performing delegated UM functions. Participate in all NCQA and CMS audits as QA subject matter expert for the UM process and oversight.
Essential Duties and Responsibilities include the following. Other duties may be assigned.
- Acts as a subject matter expert for area of responsibility, ensuring CMS and NCQA guidelines are met.
- Support direct operations of the team (such as being readily available to answer questions from team members and vendors on UM process) as necessary.
- Monitor internal team members by performing monthly record audits in accordance with the organization standards and CMS guidance.
- Monitor external vendors delegated for UM by leading quarterly audit calls to review their UM performance in accordance with the organization standards and CMS/NCQA guidance.
- Conduct new staff training and re-training in areas of policies, procedures, and workflow processes.
- Handle multiple tasks and complete work under tight deadlines
- Understands and provides accurate information regarding Medicare Advantage products courteously and professionally.
- Conducts accurate research to resolve issues identified as part of quality monitoring and regulatory adherence.
- Reviews training/educational material and seek clarification when needed and provides real-time education to UM staff.
- Maintains strict confidentiality of all sensitive information.
- Maintains compliance with all company policies and procedures.
- Achieves and maintains acceptable performance levels according to the UM regulations.
- Utilizes documents using Microsoft Office and other applicable software, as designated by management.
- Performs general clerical duties to include but are not limited to: photocopying, faxing, mailing, and filing.
- Previous experience in Managed Care and Medicare/Medicaid is required.
Supervisory Responsibilities
This job has no supervisory responsibilities.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience
Registered Nurse with active FL license; Two to three years related experience and/or training; or equivalent combination of training and quality management education and experience
Computer Skills.
To perform this job successfully, an individual should have an expert working knowledge of Microsoft Office software, including Microsoft Excel and Word as well as MS Internet Explorer.
Other Qualifications
CQPA Quality certification is a plus.
This is a fully remote position working from home.
Pay: $75,000.00 - $80,000.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Vision insurance
Work Location: Remote
