Senior Quality Analyst (Claims)

About the role

Perform audits and/or provide oversight and guidance to Claim Auditors in completing comprehensive random audits of claims, membership, and service inquiry adjustment transactions. Determine the root causes of error and recommend appropriate corrective actions to prevent re-occurrence. Support cross-functional Business Transformation initiatives with quantitative transactional analyses and sample audits, as well as problem definition and resolution for business improvement and integration projects.

Responsibilities

• Perform timely post-payment audits of all claim types to verify the accuracy of claim payment and processing.
• Perform cycle time analysis and audits of root cause and corrective actions for EmblemHealth.
• Conduct comprehensive audits of service inquiry adjustment transactions to ensure inquiries from groups, providers, and subscribers are resolved accurately and timely.
• Conduct special audits as directed by senior management, including subcontracted operational capabilities.
• Provide problem definition and analysis support to Business Transformation Leaders and their associated process improvement projects.
• Review and evaluate management responses and corrective action plans related to audit findings; negotiate disputed findings and recommendations with area management.
• Analyze audit results to identify root causes of errors and develop cost-effective recommendations.
• Work with Claims, PFO, PNM, Membership, and IT to identify system logic modifications related to audit findings.
• Participate in the external audit process, provide instruction to auditors, and research and coordinate responses to specific audit issues or questions.
• Perform comprehensive reviews of new product or system implementations, verifying system data files and accurate claim adjudication in accordance with contractual benefit provisions.
• Regular attendance is an essential function of the job.
• Perform other duties as assigned or required.

Qualifications

Bachelor’s Degree required; additional year of experience and/or specialized training may be used in lieu of educational requirement.

• 3–5 years of relevant work experience, preferably in auditing and improving operational processes.
• Prior extensive experience in quality and/or root cause analysis.
• Prior knowledge in insurance coding and/or claims experience.
• Knowledge of EmblemHealth’s processes and Facets system preferred.
• Strong problem-solving and verbal and written communication skills.
• Advanced PC literacy with emphasis on Cognos, MS Excel, and MS Access.

Pay

Hiring range: $56,160–$99,360