Senior Claims Qa Auditor - Paramount - Remote

Paramount Health Care, a ProMedica Health Plan, offers insurance products across six Midwest states. This Ohio-based company, headquartered in Toledo, has more than 685 employees dedicated to serving their health plan members.

Paramount offers Medicare Advantage and Marketplace Exchange health plans for individuals and families. Paramount maintains accreditation by the National Committee for Quality Assurance (NCQA) for their HMO and Medicare Advantage products.

In addition, Paramount has a full complement of insurance products for employers of any size, including medical, dental, vision and workers’ compensation, as well as vocational rehabilitation, life-care planning and wellness.

As a part of ProMedica, Paramount is driven by ProMedica’s mission to improve your health and well-being. ProMedica has been nationally recognized for its advocacy programs and efforts to address social determinants of health. Paramount strives to provide an exceptional experience to every member. For more information about Paramount, please visit our website at paramounthealthcare.com.

Basic Purpose:

Perform quality assurance functions as they pertain to claims transactions audits by means of identifying, documenting, and communicating information. The Senior Claims QA Auditor is responsible for the development and maintenance of statistical reports and to provide those to claims management on a regular basis. Must work cooperatively with the claims trainer and claims team leaders to propose and implement solutions to ensure best outcomes for our groups, members, and providers. Primary auditor for all activities related to internal/external audits to ensure timely dissemination of requested information/materials.

Primary Duties:

• Perform QA review of random claim samples as they relate to claim adjudication, claim adjustments, and batch adjudication to ensure internal department standards, third party payer, and governmental requirements are met for QA standards.
• Maintain and Disseminate QA information/findings to claims staff in a timely manner using the current agreed upon process outlined (e.g., via email) in a clear and professional manner
• Demonstrated ability to takes initiative to work with claims trainer to identify, document, and propose solutions for areas of variations from the norm, or potential high-risk areas requiring further one-on-one or group training
• Develop, implement, and maintain worksheets that support the overall details of the QA program within the claims department. Provide the Director of Claims and team leaders with timely detailed monthly reports that outline departmental and individual statistical results.
• Coordinate with the Claims Trainer to produce and/or update documentation on claims processing procedures as they relate to QA reviews. Provide recommendations based on findings.
• Perform claims audits for employer audit, governmental agencies or as assigned in a timely and efficient manner by assembling materials, preparing agenda, printing system reports and providing appropriate documents for review.
• Present results in a concise and clear manner, and provide answers to all questions from auditors or other sources
• Perform other duties as directed to support claims functions, which are focused on achieving both departmental and organizational objectives.
  

General Information/Qualifications:

• Associates degree in Finance/auditing required.
• Minimum five years of experience with claims processing and adjustments, COB, and payment refunds for all lines of business and all types of claims required.
• Spreadsheet and database skills required. Demonstrated Excel at least level 2 or above. (PMU class)
• Excellent written, verbal, and interpersonal communication skills required.
• Quality assurance program experience highly desirable.
• Experience or strong working knowledge of benefit/pricing configuration, provider database maintenance, or related configuration experience desired.
• Good working knowledge of HCFA, State of Ohio and Michigan compliance regulations, and institutional/professional ECS submission formats highly desirable.
• Demonstrated ability to handle detail and maintain confidential information.
• Ability to prioritize and handle large volumes of work.
• Ability to work in a production environment that can be stressful.
• Maintain a high level of motivation, initiative, and accountability.
• Ability to work independently; plan, coordinate, and organize multiple priorities.
• Ability to operate general office equipment; ability to communicate on telephones and move between company work stations.

ProMedica is a mission-based, not-for-profit integrated healthcare organizational headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org

Equal Opportunity Employer/Drug-Free Workplace