"We will use our role as the area’s leading health insurer to provide affordable access to healthcare and to improve the health and wellness of our members."
Summary of Position:
Provides quality assurance review of claims, inquiries and member services transactions; and procedural, system, and technical support and guidance to the Operations units and management staff.
Essential Accountabilities – Other duties may be assigned:
* Performs Quality Assurance (QA) functions – reviews all work types accurately and timely, including performance guarantee groups, for Claims, Customer Service and Member Services to ensure that quality standards are being met.
* Provides coaching and feedback to Operations and Membership staff through unit rounding and in-unit rotation time. Makes suggestions for training to Operations and KEG management staff.
* Identifies, investigates and defines system and clerical problems and trends that impact quality or productivity, and reports these to management for issue resolution.
* Participates in the development of SOPS and training modules by reviewing and testing all documentation. Identifies best practices and documents for use in training and coaching of new employees.
* Participates in system testing in order to identify problems prior to system implementation.
* Provides daily, weekly, and monthly reports to management regarding the performance of employees they are assigned to review. Keeps an accurate record of productive time and completes the work detail log on a timely basis.
* Consistently promotes customer satisfaction for both internal and external customers.
Principal Challenges – List the most typical and/or most complex problems or challenges faced in performing the job:
* Ensuring that error trends are quickly identified and communicated in order to prevent multiple processing and MTM errors.
* Avoiding conflict in the process of error disputes and resolutions.
* Identifying, during unit rounding and in-unit rotation, inconsistencies in processing or procedures practiced in the units.
Supervisory Responsibilities (if applicable):
Qualifications – The following qualifications are representative of the basic knowledge, skills and abilities required to perform this job at a satisfactory level. Reasonable accommodations may need to be made to enable individuals with disabilities to perform the essential functions:
* Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures or government regulations.
* Ability to write reports, business correspondence and procedure manuals.
* Ability to speak effectively before groups of customers or employees of the organization.
* Ability to add, subtract, multiply and divide using whole numbers, common fractions and decimals.
* Ability to compute rate, ratio, and percentage and to draw and interpret bar graphs.
* Ability to solve practical problems and deal with a variety of concrete variables in situations where limited standardization exists.
* Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.
Other (please specify)
* Ability to work independently without close supervision.
* Flexibility and adaptability to constant change.
* Strong attention to detail and accuracy (as demonstrated in current position).
* Consistent portrayal of a professional image and demeanor.
* Requires the ability to use independent judgment and make decisions.
Knowledge and Skills:
* Intermediate level keyboard skills.
* Intermediate level knowledge of and ability to use Microsoft Windows and Office (Excel, Word, Access, and PowerPoint).
* Medical Terminology and ICD/CPT Coding knowledge is required
Education and Years of Experience:
High school diploma or general education degree (GED) plus two years of advanced education or technical training in the medical insurance field, and at least 5 years of directly related experience in medical insurance operations (claims, customer service, or member services); or any combination of education and experience providing the types and levels of knowledge, skills, and abilities required by the job.
Certification, Licenses, Registrations Required:
Physical Demands – The physical demands listed are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.:
Position is mostly sedentary; however, may need to stand and walk occasionally throughout each day. Must be able to use fingers, hands and arms to operate a computer keyboard frequently each day. Must be able to speak and hear clearly in order to give and receive information. Typically, no lifting or exertion of force is required, but may need to lift a box of 5-10 pounds on occasion. Close vision is necessary for viewing a computer screen and for reviewing employee work.
Work Environment - Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.:
Work is performed in an environmentally controlled home setting with no exposure to adverse conditions. Employees must meet broadband internet requirements with one of the contracted vendors.
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