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.
DentaQuest - 2 years ago