The primary purpose of this position is to perform audit and quality review processes in accordance with Claims Department Policy & Procedures.
· Conducts random quality review daily.
· Conducts Contract Approval audits including Payor Summaries and Fee Schedules.
· Prepares and presents feedback on deficiencies identified in accuracy, timeliness, or quality to Claims Supervisor.
· Identifies unique issues and problems within assigned areas of responsibility. Researches and formulates solutions in conjunction with Claims Supervisor.
· Analyze and validate claim audits, health plan and state specific reporting.
· Assists in the preparation for health plan audits, including assembling support materials and copying of claims and claims reports.
· Processes claims requiring special handling.
· Reviews and releases aged claims on daily Pend Report.
· Performs audit on new staff to ensure 100% accuracy.
· Maintains confidentiality of all claims files, audit reports, and related claims data.
· Prepare standardized weekly and monthly reports.
· High School Diploma or equivalent.
· Minimum 2 years’ experience performing Claims Processing or Analyst duties.
· Advanced experience with MS Word, Excel and Access.
· Knowledge of managed care operations, accreditation guidelines and state requirements.
· Strong analytical and problem solving skills with d emonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.
· Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
· Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
· Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
· Ability to effectively organize, prioritize, multi-task and manage time.
· Demonstrated accuracy and productivity in a changing environment with constant interruptions.
· Ability to exercise strict confidentiality in all matters.
Mobility - Primarily sedentary, able to sit for long periods of time.
Physical Requirements – Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in oral and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs.
Environmental Conditions - Usual office setting.