Responsible for all aspects of quality assurance within the Claims job family. Conducts audits and provides feedback to reduce errors and improve processes and performance.
Responsibilities and Accountabilities
• Has basic knowledge of theories, practices and procedures related to claims/ claims quality
• Performs routine or structured work.
• Responds to routine or standard requests.
• Uses existing procedures and facts to solve routine problems or conduct routine analyses.
• Depends on others for instruction, guidance or direction.
• Performs queries on relevant claims systems in order to obtain relevant information for audits
• Validates claims data, member data, provider data against information from claims processing or business processing systems to ensure that data/decisions/payment and recovery/settlement information is accurate
• Analyzes claims data against applicable policies and regulations to identify potential issues (e.g., member benefits, provider contracts, billing anomalies, payment accuracy, claims processing system issues, state mandates)
• Reviews history of related claims to pull in and understand additional claims-related information
• Maintains reporting infrastructure, as appropriate (e.g., SharePoint, Access databases)
• Calculates dollar amount of financial claim errors/defects
• Develops and delivers fact-based audit determinations in an objective, non-confrontational manner
• Escalates issues identified during the audit cycle or rebuttal process to applicable stakeholders, as appropriate (e.g., Subject Matter Experts, Operations Team, Quality Team, business partners, team leads)
• Ensures compliance with applicable audit and rebuttal timelines (e.g., calibration timelines, rebuttal timelines/form completion, workflows, turnaround time)
• Achieves production quality goals/metrics (e.g., audits per hour, audit accuracy, first-pass accuracy, rebuttal accuracy)
• Provides supporting documentation for audit findings
• Manages audit inventory to ensure proper workload balance, coverage and closure
• Identify/communicates escalated errors/defects and ensure proper resolution, as needed (e.g., calibrations, rebuttals, appeals)
• 1-2 years prior experience in a transactions based operation
• Prior knowledge/experience with account based products
• 1-2 years of experience within a matrix organization, healthcare or insurance company
Training and Skills (include professional licenses and certifications):
• Interpersonal Skills - ability to deal and work with people with different backgrounds.
• Decision-Making Skills - capable of arriving at the appropriate decisions after weighing the pros and cons of all the options in consultation with department managers/SME’s.
• Communication Skills - excellent verbal and written communication skills in addition be a good listener to give value to the opinion and suggestion of others.
• Accountability – Takes ownership of tasks, performance standard and quality results. Maintains necessary attention to detail to achieve high level performance.
• Problem Solving - Solution Driven Approach Skills - demonstrate ability to review problem, troubleshoot root cause issues and determine path to resolution with appropriate guidance.
• Flexible - Able to work effectively in a changing environment and contribute innovative ideas.
• Accuracy and Efficiency - Excellent time management and organizational skills balancing multiple priorities. Accurate when processing detailed tasks while meeting deadlines.
• Self-starter, able to independently, drive work and prioritize work with moderate oversight.
• Beginner to Intermediate MS Office skills including MS Word, MS Excel, and demonstrated ability to understand basic excel data structure.
• Ability to be trained in Claim Adjudication Understanding
Mary Kraft Staffing and HR SolutionsMary Kraft Staffing was founded in 1989 by Maryland native Mary Kraft and has since partnered with industry-leading healthcare, financial, commercial, insurance and service industry clients to increase productivity and drive cost savings through an array of flexible, cost-effective staffing and outsourced HR options. Each year, Mary Kraft's winning combination of industry-leading staffing expertise and high-quality talent enables hundreds of outstanding companies to respond to ever-changing business needs with unparalleled success.