Virginia Birth Injury Fund

Position Overview   
 

The Quality Analyst, housed within Policy & Quality and reporting to the Policy & Quality Manager, supports audit readiness, program integrity, and consistent execution of Program operations through structured quality assurance and validation activities. With an initial focus on Benefits, this role conducts targeted reviews of claims and documentation to ensure decisions are accurate, well-supported, and aligned with program requirements. The Quality Analyst also establishes tracking mechanisms to identify trends, strengthen processes, and improve consistency, while serving as a point of coordination for provider-related inquiries to support clear, reliable interactions across the Program. 

The Quality Analyst conducts structured reviews of adjudicated claims to validate accuracy, completeness, and compliance with regulatory and program policy, payer sequencing requirements, and documentation standards prior to or following payment, based on risk. The role also supports provider assessment functions by serving as a consistent point of contact for inquiries, ensuring accurate communication and clear documentation, and creating visibility into recurring provider questions or risks. 

Working across Benefits, Case Management, and Policy & Quality, the Quality Analyst reinforces disciplined operations, reduces variability, and helps ensure the Program can withstand internal and external scrutiny. This position is Exempt under the Fair Labor Standards Act (FLSA). 

Duties & Responsibilities: 

Claims Validation, File Quality & Defensibility (Audit Readiness) 

• Conduct targeted and sample-based reviews of adjudicated claims and related records to assess:  

• Completeness and quality of documentation  

• Clarity and sufficiency of decision rationale  

• Alignment with program policy, statute, and internal standards  

• Correct application of payer sequencing requirements (including Medicaid considerations)  

• Apply a risk-based validation approach:  

• Pre-payment review for high-risk claims (e.g., high-dollar, complex payer scenarios, exceptions)  

• Post-payment sampling for routine claims  

• Identify and flag:  

• Errors, inconsistencies, or deviations from standard processes  

• Documentation gaps or unclear justification that may impact audit defensibility  

• Return claims for correction or escalate issues as appropriate, while maintaining clear separation from adjudication authority  

• Document findings in a structured, objective manner and maintain logs of:  

• Reviewed claims  

• Error types and root causes  

• Trends and recurring issues  

• Assess timeliness of processing and completion of key workflow steps, in addition to documentation quality  

• Contribute to defining and reinforcing standards for complete, consistent, and audit-ready claim files 

Tracking Infrastructure (Visibility & Control) 

• Establish and maintain structured tracking mechanisms, including:  

• exception log  

• appeals log  

• provider inquiry tracker  

• Maintain visibility into third-party administrator (TPA) performance issues through consistent tracking and documentation of errors, delays, and rework 

• Ensure consistent categorization, data entry standards, and usability of tracking tools  

• Support adoption of tracking practices across teams to improve visibility and consistency  

• Maintain organized records that can be used to demonstrate program activity, trends, and responsiveness during audits or reviews 

• Partner with Benefits and Policy & Quality to address root causes and recommend process improvements 

Structured Issue Identification (Risk & Pattern Recognition) 

• Review outputs from file validation and tracking systems to identify:  

• recurring documentation gaps  

• inconsistent application of program requirements  

• repeat issues affecting providers or families   

• Document patterns clearly to support awareness of potential risks and vulnerabilities to inform future process improvements 

• Distinguish between isolated issues and recurring patterns to support clear identification of potential systemic risks 

• Elevate findings through established channels to support timely review and action  

Escalation Readiness Support (Decision Support) 

• Support preparation of clear, structured summaries of complex or non-standard cases, including:  

• relevant facts  

• applicable authority (statute, policy, or guidance)  

• nature of the issue or exception  

• Ensure documentation supporting escalations is complete, organized, and suitable for leadership, Board, or external review 

• Contribute to consistent, transparent handling of escalated items  

Quality Monitoring & Process Improvement 

• Analyze validation findings to identify recurring errors or inconsistencies and highlight areas of operational risk  

• Partner with Policy & Quality to improve standard work, guidance, training, and strengthen alignment between policy and operations  

• Support development and refinement of adjudication standards, documentation requirements, process controls 

Provider Assessment Coordination & Inquiry Support 

• Serve as a point of contact for medical providers regarding assessment-related inquiries  

• Provide accurate, consistent, and well-documented responses aligned with program requirements  

• Track and organize provider inquiries to ensure visibility into:  

• volume  

• common questions  

• areas of confusion or inconsistency  

• Support accurate interpretation and communication of assessment-related requirements to reduce errors, confusion, and potential revenue risk 

• Identify and elevate recurring provider issues that may indicate gaps in communication, process clarity, or program requirements  

• Maintain organized records of provider interactions to support transparency and audit readiness  

Additional 

• Maintain a high level of confidentiality and abide by HIPAA rules and regulations. 

• Other duties as assigned 

Qualifications: 

• Strong attention to detail and commitment to accuracy  

• Analytical thinking and ability to identify patterns and inconsistencies  

• Sound judgment in assessing documentation and risk  

• Ability to distinguish between isolated issues and broader patterns 

• Clear, structured written communication  

• Ability to organize and maintain consistent records and tracking systems  

Education & Experience: 

• Bachelor’s degree or equivalent combination of education and relevant experience 

• Experience in healthcare operations, claims, quality assurance, or program analysis  

• Familiarity with regulated environments or benefit programs preferred  

• Experience conducting audits, file reviews, or quality monitoring activities  

• Experience in collaboratively approaching when working across teams 

• Strong Excel and data organization skills  

Virginia Birth Injury is an Equal Opportunity Employer. Virgina Birth Injury does not discriminate in hiring or employment practices based on race, color, religion, gender, age, sexual orientation, marital or family status, national origin, non-job-related disability, or status as a veteran.