Claims Quality Analyst

About the role

The Claims Quality Analyst is responsible for reviewing claims to ensure correct payments are made. This position involves analyzing data to identify irregularities, recommending process improvements, and assisting in training.

Responsibilities

• Audit daily processed claims through random selection based on set criteria.
• Document, track, and trend findings per organizational guidelines.
• Based upon trends, determine ongoing Claims Examiner training needs, and assist in the development of training curriculum.
• Conduct in-depth research of contract issues, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends. Recommend actions/resolutions.
• Work with other organizational departments to develop corrective action plans to improve accuracy of the claims adjudication processes and assure compliance with organizational requirements and applicable regulations.
• Assist in the development of Claims policies and procedures.
• Provide backup for other trainers within the department.
• Assist in training of new departmental staff.
• Assist with the research and resolution of audit appeals.
• Assist with external/internal regulatory audits.
• Identify policies or common errors requiring retraining sessions.
• Participate in quality projects as required.
• Collect, analyze data, identify trends, write reports (i.e., the monthly and quarterly reports) and present findings to the appropriate claims service management personnel.
• Other duties as assigned by senior management.

Requirements

• Associate degree required; Bachelor’s degree preferred.
• Minimum of 4 years of experience performing claims quality audits in a NYS-based managed care setting.
• Expertise in both professional and institutional claims coding, and coding rules required.
• Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and standard industry reimbursement methodologies required.
• Strong knowledge of CMS Medicare and NYS regulations required.
• Experience in training development and presentation preferred.

Professional Competencies

• Strong organizational, analytical, and oral/written communication skills required.
• Proficiency in PC application skills, e.g., excel, word, PowerPoint, etc.
• Must be able to follow direction and perform independently according to departmental requirements.

Benefits

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week.
• Retirement Savings and Pension Plans.
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts.
• Loan Forgiveness Programs for eligible employees.
• College tuition discounts and professional development opportunities.
• College Savings Program.
• Union Benefits for eligible titles.
• Multiple employee discounts programs.
• Commuter Benefits Programs.