Claims Quality Analyst

Description

• Work within the claims department to ensure the correct configuration and functioning of the primary claims processing systems.
• Perform technical and analytical work to support the functional and reporting requirements of the claims unit.
• Consult and collaborate with Claims Department supervisors and leads to address any issues that are contributing to inaccurate or inefficient processing of claims within the Department.
• Manage all requests for system improvements and problem resolutions.
• Interface with configuration department, IT departments, and other areas within the company to ensure that all issues identified by claims department are addressed quickly and effectively.
• Maintain an up-to date knowledge of national and state-wide code sets, standards and regulations pertaining to the handling of claims documents and assist Supervisors within the claims department in identifying, remediating, and resolving issues interfering with the accurate and timely adjudication of claims.
• Play an active role in identifying business requirements and workflow associated with the upcoming QNXT implementation.
• Must demonstrate leadership and interpersonal communication skills by working collaboratively and effectively with peers, superiors and subordinates to accomplish objectives.

• AA degree with at least 7 years experience handling complex.
• High School diploma with at least 10 years experience handling complex and/or high dollar claims.
• Must have a strong background in analysing healthcare data and identifying both problem areas and opportunities for improvement.
• Must have at least 5 years experience working with configuration departments and IT in researching issues, identifying root causes, formulating a resolution plan, and conducting user acceptance testing.
• Must have recent experience in adjudicating claims, preferably in an MHC setting and must have recent experience working with the configuration and IT department in resolving issues related to MHC.

• Candidate must have a sound understanding of health care code sets including CPT, HCPCS, ICD-9 and revenue codes required.
• Some experience with DRG pricing is desirable.
• Must be familiar with medical terminology.
• Familiarity in working with and interpreting Provider and facility contracts.
• Must be very detail oriented and have the ability to draw conclusions from data analysis and to formulate corrective action plans when necessary.
• Must have advanced skills in using Microsoft Word and Excel.
• Must have excellent written and verbal communication skills with ability to work effectively with peers, subordinates and managers.
• Must be able to communicate effectively with other departments throughout the company and must have the ability to review issues and error reports and prioritize according to impact on the claims department and company.