The primary objective of this position is to perform routine and focus audits electronically to identify inaccurate claims adjudication.
- Performs routine and focus audits on claim processing staff and auto-adjudicated claims to identify inaccurate claims adjudication.
- Assess accuracy and consistency of claims processed for each claims processor and random sampling of auto-adjudicated claims.
- Research, trouble-shoot, and resolve errors and problem areas in electronic claim entry and/or electronic processing and notify the IT department when appropriate.
- Identify prevalent trends and recommend immediate resolution techniques to management.
- Provide quality feedback to individual claims processors and to Supervisor.
- Collaborate with other Claims staff and leadership team on the use of established business processes, procedures and related tools.
- Work with claims leadership team to identify, develop, and implement business processes and tools used by staff to improve claim accuracy results.
- Work with claim processing staff to resolve difficult or complex claims, and recommend related training opportunities that will improve claim payment results.
- Work with the Claims staff and leadership team to develop and implement new or revised business processes as required by the enterprise wide project office or compliance team (regulatory changes.)
- Demonstrate proficiency with the principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approach.
- Adhere to Interrater Reliability principles to ensure the audit results generated meet the accepted criteria by quantitatively defining the degree of agreement between two or more auditors.
- Develop and coordinate the implementation of systems, procedures and forms to improve data collection.
- Assist in the development of action plans to address quality deficiencies.
- Assist in facilitating new hire training as it relates to "Quality".
- Develop and update quality templates and Access Database with current audit review elements.
- Produce weekly, monthly, quarterly and annual management and operations focused reports.
- Assist in developing and maintaining dashboard to report Corporate and Client Quality results.
- Two to four year College Degree in Finance or Healthcare preferred. High School diploma/GED Required.
- 2 or more years of Claims Processing experience in health care industry, preferably in an auditing role
- Ability to analyze, interpret and apply business and operational policies and procedures for prompt and accurate claims payment.
- A thorough understanding of dependents, relationship types and eligibility guidelines to ensure consistency in validation of plan participation.
- Demonstrated excellence in data gathering, analysis, reporting and process improvements
- Ability to make sound decisions
- Ability to analyze and solve problems
- Strong interpersonal, written and oral communication skills.
- Proven logic and reasoning skills that apply methods of consistency, validity, soundness and completeness
- In depth knowledge of Windward a plus.
- Strong computer skills. Intermediate to Advanced knowledge of Microsoft Excel, Access and Word required.
PHYSICAL AND ENVIRONMENTAL CONDITIONS:
- Position is based on-site at either our Mequon, Wisconsin or Boston, Massachusetts location.
- Requires the effective use of all office equipment including, but not limited to, telephone, computers, printers, and fax machines.
- Ability to sit in front of computer terminal for extended periods of time.
- The Quality Assurance area is located in a wheelchair accessible building. The office environment is active with high voice levels and interruptions that may challenge hearing and concentration.
At DentaQuest, we make quality dental benefit programs affordable. By focusing on providing comprehensive products and services at...