Quality Assurance Analyst (Remote)

Brief Description tango is a leader in the home health management industry and is preparing for significant growth! Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care. We are currently looking for a Quality Assurance Analyst to join our growing team! PURPOSE The Quality Assurance Specialist is accountable for and oversees the following tasks: Validate claims data against information from claims processing systems to ensure that data is accurate (for both auto adjudicated claims as well as manually processed claims)Analyze claims data against applicable policies and regulations to identify potential issues (e.g., member benefits, billing anomalies, payment accuracy, claims processing system issues)Review history of related claims to pull in and understand additional claims-related informationCalculate dollar amount of financial claims errors/defectsDevelop and deliver fact-based audit determinations in an objective, non-confrontational mannerEscalate issues identified during the audit cycle or rebuttal process to applicable stakeholders, as appropriate (e.g., Operations Team, Quality Team)Ensure compliance with applicable audit and rebuttal timelines (rebuttal timelines/form completion, workflows, turnaround time)Achieve production quality goals/metrics (e.g., audits per hour, audit accuracy, first-pass accuracy, rebuttal accuracy)Provide supporting documentation for audit findingsIdentify/communicate escalated errors/defects and ensure proper resolution, as needed (e.g., rebuttals, appeals)Communicate audit findings to applicable stakeholders (e.g., error descriptions, rebuttal information)Identify, communicate, and implement opportunities for improving internal audit/rebuttal processes within the Quality teamIdentify, interpret, and utilize applicable claims and audit policies and proceduresDemonstrate understanding of how various factors may impact claims accuracy (e.g., system edits, keying vendor discrepancies, system logic)Demonstrate knowledge of the healthcare industry (e.g., billing practices, terminology, legal/regulatory requirements, coding standards)Identify and interpret applicable plan benefit information (e.g., Contracts)Maintain Claim Policies/Procedures/Job Aids to stay within Compliance annuallyOversee Annual Vendor Compliance ProcessSupport Adhoc Provider Audits QuarterlySupports Records requests/subpoenas in coordination with Compliance Essential Job Functions And Duties Oversees quality and findings in internal and external audits, all vendors and staff accuracyPerform other duties as assigned within the scope of responsibilities and requirements of the jobPerforms the essential functions of this job with or without reasonable accommodation Essential Qualifications 5 ~ 7 years of direct experience minimumAdvanced level of skills and knowledge of technical system operationsSolid understanding of enrollment and eligibility as well as claims paying for all lines of businessProfessional level training that provides a general understanding of:the administration of all contractual obligationsaudit and billing procedurespolicies and procedures how the processing of accounts receivable and eligibility requirements impacts claims processingvendor data feeds and discrepancy processadministrative and regulatory requirementstechnical workflow processesfunctional requirements of the systemsolution design documents. 4 ~ 6 years’ work experience that provides a working knowledge of:Claims billing and delinquency proceduresaccounts receivable processsystem testing and enhancement processweb portal data support Skills And Abilities Advanced level Microsoft Office skills (PowerPoint, Word, Outlook)Advanced level Microsoft Excel skillsInterpersonal, communication (written and verbal) and presentation skillsAnalytical, research, problem solving, and decision-making skillsAbility to monitor team goalsAbility to lead and coach team members tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.