Claims Quality Assurance Auditor

About the role

The Claims Quality Assurance Auditor maintains positive working relationships with internal and external customers, health plans, providers and/or members by seeking a partnership approach that will meet company goals and vision. The CQA auditor will coordinate health plan audit activities with preparation and provide preliminary results on non-compliant issues to the CQA manager. Oversees audit findings and provides education to claims staff and other internal customers within PIH. Assists with developing an audit control checklist for prevention of claims timeliness, payment accuracy, systematic or statistical errors in the PIH managed care claims system. Develops a root cause analysis report for common trends to provide feedback to the claims staff/team and/or PIH internal customers. Oversees, in conjunction with the Managed Care Management Team, to ensure QA programs are aligned with claims operations and other areas that have direct impact with claims to prevent non-compliance. Adheres to internal department standard operating procedures and applies standard industry guidelines in accordance with regulatory agencies (state and federal). Researches, analyzes and resolves complex problems dealing with claims audits, including member denials, provider disputes, deficiencies that will potentially jeopardize the claims department.

Responsibilities

• Coordinate health plan audit activities with preparation and provide preliminary results on non-compliant issues to the CQA manager
• Oversee audit findings and provide education to claims staff and other internal customers within PIH
• Assist with developing an audit control checklist for prevention of claims timeliness, payment accuracy, systematic or statistical errors in the PIH managed care claims system
• Develop a root cause analysis report for common trends to provide feedback to the claims staff/team and/or PIH internal customers
• Oversee, in conjunction with the Managed Care Management Team, to ensure QA programs are aligned with claims operations and other areas that have direct impact with claims to prevent non-compliance
• Research, analyze and resolve complex problems dealing with claims audits, including member denials, provider disputes, deficiencies that will potentially jeopardize the claims department

Requirements

• Five (5) to 10 years claims processing experience
• Claims auditing and understanding claims processing in a claims department
• Experience with implementation of Corrective Action Plan (CAP)
• Knowledge of regulatory requirements (CMS and DHS)
• High School Diploma or equivalent

Qualifications

• Bachelor’s Degree preferred

Skills

• Computer system skills/knowledge (MS Excel and Word)
• Written and verbal communication skills
• Managed Care knowledge and confidence exposure and expected knowledge of claims processing, CPT/RBRVS/ICD codes
• Level of comprehension as it relates to regulatory compliance and guidelines associated with the following: CMS, DMHC, DOI, DHS, etc.
• Analyze data understanding the trends
• Identify compliance gaps in processes and systems by providing a risk-based solution for prevention
• Prepare, issue, and track deficiencies noted during claims pre/post audit and inspection
• Extensive knowledge of root cause analysis/trends
• Organizational skills
• Ability to work independently with minimum supervision
• Meet deadlines and completion on assigned projects in a timely manner
• Ability to take initiative in analyzing problems, developing a solution with a win-win approach
• Confidentiality and honesty with compliance
• Great customer service skills with internal and external customers
• Communicate with CQA manager

Pay

$23.00–$36.70 per hour

Schedule

Days