Job Description
Position Summary The Senior Analyst, Quality Assurance & Validation serves as the enterprise owner of contract-to-claim data integrity across the billing system of record and related specialty-pharmacy platforms. The role ensures that every payer fee schedule, reimbursement rule, and configuration is validated against approved Managed Markets contracts prior to activation—safeguarding realized revenue, payer confidence, and operational compliance. Operating at the intersection of Operations, Managed Markets, Finance, and IT, this position establishes the governance, testing, and performance frameworks that uphold system accuracy, mitigate audit risk, and deliver measurable revenue protection. The QA Analyst functions as a financial safeguard, systematically identifying and correcting contractual risks that, if left unaddressed, could result in multimillion-dollar liabilities, penalties, or lost revenue. This role is critical to maximizing the return on investment for every contract by ensuring the organization captures the full value of its agreements while mitigating costly errors, disputes, and compliance exposures—driving sustainable, long-term profitability. The Senior Analyst serves as both a hands-on validator and a strategic control architect, embedding QA discipline across the payer-contract lifecycle. Essential Functions and Duties Leadership & Governance: Establish and lead the Quality Assurance & Validation framework for the billing system of record, ensuring payer-data accuracy and configuration integrity. Define validation standards, testing protocols, and approval workflows across Managed Markets and Operations. Define validation standards, testing protocols, and approval workflows across Managed Markets and Operations. Serve as primary liaison among Managed Markets, Operations, Finance, and IT on data-integrity and configuration-governance matters. Present variance analyses and QA-performance reports to leadership, recommending systemic corrective actions and process improvements. Contract-to-System Validation: Reconcile billing-system fee schedules, DRI logic, and reimbursement algorithms against executed payer contracts. Validate payer methodologies (AWP, ASP, WAC, NADAC, LQAWP, hybrid) for accuracy and currency. Audit contract uploads for hierarchy accuracy and configuration completeness prior to go-live. Maintain traceability matrices linking each configuration to its originating contract clause. Maintain traceability matrices linking each configuration to its originating contract clause. Communicate setup requirements to Intake, Reauthorization, Pharmacy, and Reimbursement to ensure seamless downstream claim processing. Operational & Financial Quality Assurance: Partner with Operations and Finance to monitor payer-level reimbursement accuracy and margin preservation. Conduct pre- and post-implementation audits to verify compliance with contractual and regulatory standards. Lead root-cause analyses of revenue variances or denials tied to configuration or data discrepancies. Maintain validation dashboards and provide executive QA reporting. Cross-Functional Collaboration: Collaborate with Managed Markets on contract interpretation to ensure validation aligns with executed payer terms. Partner with IT and Database Administration to test configuration updates and enhancements in staging environments. Interface with Reimbursement and Intake teams to confirm claim accuracy and data continuity. Engage with Managed Markets for clarifications or change notifications—without altering, negotiating, or uploading contract terms. Identify and implement automation opportunities within the billing system or related workflows. Process Improvement & Automation: Develop standardized QA documentation templates, audit checklists, and validation-trail tools. Identify and implement automation opportunities within the billing system or related workflows. Recommend system enhancements to improve visibility, data quality, and control efficiency. General Responsibilities: Adheres specifically to all company policies and procedures, Federal and State regulations, and laws. Display dedication to position responsibilities and achieve assigned goals and objectives. Always represent the Company in a professional manner and appearance. Understand and internalize the Company’s purpose. Display loyalty to the Company and its organizational values. Display enthusiasm and dedication to learning how to be more effective on