Medical Claims Quality Assurance Specialist

SUMMARY

Responsible for audit of claims payments to providers, ensure appropriate claim decisions based on various provider contracts, authorizations and health plans’ benefits are addressed during adjudication whether manual or auto adjudication. Conduct evaluation of claims adjudication performance per plan provisions, eligibility, verify data input, identify correct benefit level, calculate fee schedule, and claim corrections. Responsible for monitoring and mentoring members of the claims team on their performance and accuracy on daily work and special projects.

DUTIES & RESPONSIBILITIES

- Perform audits on accurate and timely adjudication of professional and institutional claims according to state and federal regulations.

- Perform audits on the adjudication and adjustment of claims ensuring the appropriate coding and billing guidelines are followed, and appropriate Claim Adjustment codes are applied.

- Work with internal operations and project teams to solve claims-related problems, benefit plans research and provider contract interpretation and configurations resulting in non-examiner fault findings

- Audit recordings of incoming calls and disputes from providers, customers, vendors, and internal groups, to successfully analyze the needs, research information, answer questions, and resolved issues and/or disputes in a timely and accurate manner.

- Track provider disputes in CRM to ensure appropriate claims dispute resolutions and communication to provider relations

- Ensure referral authorization are applied per UM Departmental Policy and Procedures and specific contracted Client's / Payer process.

- Generates written performance outcomes from claim audits

- Responds and assists other departments with complex issues for resolution or affirmation of previously processed claims and existing guidelines.

- Determines and processes underpayments (internal errors) and provider reimbursement requests, which may involve the use of spreadsheet research and correspondence.

- Maintains the department’s claim edit rules and processing claims according to client specific verification of eligibility, interpretation of program benefits and provider contracts to include manual pricing, CARC/RARC assignment

- Identify issues negatively impacting the provider community including but not limited to system set up, required benefit modifications, EDI logic, provider education, claim examiner errors, and authorization rules.

- Identifies trends in claims flows and suggests process improvements.

- Assist in preparation with Claims Audits.

- Mentored others on the team and served as a subject matter expert and primary contact for claims related functions and activities.

REQUIREMENTS

- Associate Degree in healthcare, or equivalent certification or work-related experience.

- 5 years’ experience in claims operations environment in healthcare processing Medicare.

- Hands-on working experience processing medical claims on the payor’s side.

- Knowledge of Medicare Fee Schedule and alternative payment methods (cap, flat fees).

- Knowledge of medical terminology and comprehension in the usage of CPT Codes, ICD-10 Codes and Revenue Codes (knowledge of ICD-9 codes is a plus).

- Strong knowledge and experience processing UB92 and HCFA 1500 claims.

- Knowledge of National Correct Coding Initiative (CCI) Edits.

- Detailed knowledge of electronic billing processes universal billing forms.

- Experience in gathering all necessary documentation required during internal and external Audits.

- Knowledge of CMS/ACHA regulations.

- Strong command of Excel, PowerPoint, Word & Outlook.

- Excellent written and verbal communication skills.

- Ability to manage multiple priorities.

- Excellent problem-solving skills, good follow-up abilities and willingness to be flexible and adaptable to changing priorities.

- Self-starter, ability to work independently and in a team environment.

- Strategic, analytical, process oriented and must have critical thinking skills.

- Certified Professional Coder (CPC) is desirable.

- Collections, Billing, and Accounts Receivable experience is desirable.

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Paid training
• Vision insurance
• Work from home

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Supplemental Pay:

• Bonus pay

Ability to commute/relocate:

• Miami, FL: Reliably commute or planning to relocate before starting work (Required)

Application Question(s):

• Please advise your salary expectations (providing a range is acceptable)

Education:

• Associate (Preferred)

Experience:

• Claims Processing: 5 years (Required)
• Medicare: 2 years (Required)
• Medical coding: 1 year (Required)
• Medical billing: 1 year (Required)

Work Location: One location