Claims Quality Assurance Analyst

Summary: Position is responsible for developing and conducting monthly Quality Assurance (QA) Audits to determine claim processing/payment accuracy in accordance with health plan benefit design and established desktop procedures. This position is responsible for providing reports/presentations outlining findings, trends, and corrective actions needed within processing systems or with staff training.
Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Establishes QA auditing protocol to evaluate accuracy of claim processing.
• Conducts monthly QA audits of adequate sample size on a timely basis.
• Creates documentation/reports/presentations on processing accuracy, trends, and areas for improvement.
• Conducts weekly QA audits of 10 to 15 claims per Claims Analyst to evaluate accuracy.
• Provides direct feedback to claims analyst with error findings, correct processes, and request mitigation.
• Creates documentation/reports on each staff member’s accuracy/trends/areas of improvement and provides to Manager/Sr Manger monthly with limited direction, translates regulatory and business requirements to technical specifications for claims configuration including process documentation.
• Perform root cause analysis on identified errors; collaborate with other stakeholders to develop mitigation plans.
• Utilizes a detailed understanding of insurance, processes, and business systems to drive the research and analysis of the defined problem, design the recommended solution, and implement the solution, while addressing associated change management.

Candidate Qualifications
Education
Bachelor’s Degree or at least 7 years commensurate experience is required; Bachelor’s Degree in business or health care related field preferred
Licenses/Certification
None required; CPC preferred.
Skills

• Strong knowledge of health insurance industry with all product lines (Medicare, Medicaid, Commercial, ASO, DSNP, etc…)
• Extensive knowledge of claims policies and procedures including regulatory requirements and industry standards from AMA, CMS and CCI edits.
• Strong computer skills, specifically with Microsoft Office and Windows.
• A desire to serve others while being empathetic with the drive to go above and beyond to help resolve questions at the first point of contact.
• Must have a strong work ethic and a sense of responsibility to other team members and external stakeholders to meet all needs represented by a robust sense of accountability
• Adaptable and a quick learner, willing to change to meet shifting customer and business needs.
• Excellent verbal and written communication skills
• Extremely organized and detail-oriented.
• The ability to develop effective working relationships, and work collaboratively with all levels of staff, vendors, and partners.
• Ability to work independently on a variety of projects in a high volume, fast paced, and sometimes nebulous environment
• Demonstrated pattern of growth in ability to lead, motivate, develop and mentor others
• Solid business acumen, decision making, research and analytical skills

Experience
Minimum three (3) years of claims and health care administration and/or managed care experience.
Experience developing/conducting claims QA audits in health care industry.