Performs quality audits for enrollments, complex claims, provider quality, credentialing, bill review, adjustments, and pre-authorization requests for all physician, facility, and specialty claims in accordance with company policies and procedures in a timely manner that meets or exceeds productivity and quality goals.
Performs prospective and retrospective reviews of Appeals & Grievances casework to ensure that complaints are handled within Medicare and operational guidelines.
Maintains records and prepares reports on quality audit results. Quality results include accuracy rates, turnaround times, denial rates, error trends, and operational effectiveness.
Reviews and analyzes procedures and workflow and to make recommendations for streamlining the grievance and appeals process within the functional units of the department.
Evaluates quality audit procedures, including quality scorecards, matrixes, audit point sheets and trending for Executive Management review.