Claims And Quality Mgmt System Auditor

Overview:
Summary
The role of Claims and Quality Management System Auditor is a vital role for Your Hearing Network (YHN). The role entails detail orientation managing oversight of ensuring the highest quality of processing of claims, accuracy for documentation and management of complain processes. This role reports directly to the Chief Operating Officer (COO) of Birdsong Hearing Benefits, a sister company to Your Hearing Network. The COO also has responsibility for the YHN operations. Duties and responsibility entail the ability to develop and adhere to company quality assurance principles, create effective testing procedures, diagnose, document and correct quality complaints and issues, identify and execute training needs, and collaborate with internal teams to analyze system requirements and claims coding. This role also has responsibility for identifying, developing and conducting training delivery. The role will oversee the training delivery, providing on-the-job training (OJT) and post-training support through developing appropriate and through training material and programming to support annual quality training.
The auditing function requires a detailed-oriented oversight of quality control processes. The role will develop testing parameters, review processes to industry standards, and assess procedures. Training of other staff and sharing detailed results with the executive team, are required of this role.
Responsibilities:
ESSENTIAL JOB FUNCTIONS
Key Accountability Metrics

• Plan, coordinate, develop and implement approved projects in order to enhance the overall efficiency of operational procedures, methods, controls and performance.
• Responsible for compiling and reporting trainee performance up to various levels of leadership, following each training course.
• Provide leadership team with status of projects; issue, communicate and recommend policy decisions to achieve project objectives.
• Perform special audits of provider payments for payers as requested by regulators, contracting, and internal management.
• Represent department as requested on work groups and special assignments, including related testing.
• Requires knowledge of claims processing for HCFA.
• Function as subject matter expert specific to the audit function and claims.
• Identify documentation or delivery defects and gaps presenting recommendations as required.
• Maintain training materials/curriculum and documentation for Claims Processors and Billing Specialist as well as Customer Service Representatives.
• Work closely with management and supervisory staff and other subject matter experts in order to coordinate and deliver training as well as analyze and develop training and/or documentation needs.
• Develop and implement quality control audit plans.
• Identify testing parameters for auditing purposes and validity.
• Assign team members to quality audits and oversee their work, if applicable.
• Train employees on quality standards and procedures.
• Ensure that processes comply with industry standards.
• Document defects and recommendations for improvement.
• Prepare and present quality audit reports to senior management.
• Keep abreast of industry standards and regulations.
• Utilize up-to-date technical skills to navigate through electronic leadership tools and platforms; with the ability to test new tools as required.
• Perform analytical claims/call issue review to develop training opportunities
• Develop SOP/Desk-level procedures to ensure quality outcomes.
• Be responsible for overseeing policy and procedure review and completing full/complex desk or pre-delegation, annual or follow-up onsite audits/assessments of delegated entities, including vendors, in support of the regulatory, CMS and NCQA requirements.
• Research, investigate and oversee delegated entity’s compliance with reporting requirements by tracking the receipt and evaluating the completeness of reports.
• Provide highly complex analyses and defines efficiency in relation to compliance programs and internal controls.
• Collaborate on regulatory audits, and findings responses.
• Assist in the development of delegation policies and procedures and associated staff training.
• Assist in the development of audit tools, correspondence templates, etc. to external entities.
• Conduct thorough assessments and audits of processes, procedures, and documentation to ensure alignment with established quality standards, regulatory requirements, and organizational objectives.
• Initiate and maintain cooperative relationships with co-workers, managers and supervisors, claimants, and members of the public.
• Performs increasingly difficult office audits of Claims and other business records and documents to determine or verify compliance with laws and regulations.
• Maintains records and submits oral and written reports concerning cases and activities.
• Perform other duties as assigned
• inspect a product or system to ensure that it meets the set specifications and standards, write audit reports and assessments, and develop quality control monitoring protocols

Qualifications:
PROFESSIONAL EXPERIENCE/QUALIFICATIONS
Requirements and Must Have Criteria

• Four (4) years’ experience which must include specified years of experience specific to claims administration, quality assurance and/or auditing functions.
• Proven experience in group presentations, leading and/or involvement in special projects, preparation of employees for job responsibilities through conducting OJT, performance evaluation feedback, coaching, etc.
• Ability to design and produce training materials based on the Instructional Design Process.
• Demonstrated attention to detail for auditing practices, clear, consistent communication and
• Knowledge of Adult Learning Principles.
• Good verbal and written communication skills.

Other Personal Characteristics and Experience

• Demonstrate an entrepreneurial spirt
• Willingness to go above and beyond daily to achieve best in class results
• Ability to work with highly detailed, complex and emotionally sensitive information.
• Ability to maintain a high degree of discretion, confidentiality, protection, and integrity.
• Ability to learn complex processes, medical terminology, technology systems, and progressively develop data analytics skill set.
• Ability to prioritize and complete multiple complex work assignments.
• Ability to work independently.
• Understand complex organ donation processes.
• Understand minimal medical terminology.
• Excellent written and verbal communication skills.
• Ability to provide constructive feedback in a clear, concise, and respectful manner.
• Demonstrated ability to meet deadlines.
• Knowledge of quality assurance, quality systems, internal auditing, and/or quality improvement preferred.
• Basic knowledge of data analysis, statistics, data integrity, and analytics with initiative and ability to further develop skills.

EDUCATION

• Bachelor’s degree in education, Instructional Design, Communications or related discipline is required.

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On-the-job training