Claims QA and Compliance Officer

POSITION OVERVIEW

FLSA: Exempt, Full Time

Department: Claims

Primary Worksite: 6 West Colony Place, Durham, NC

Supervisory Responsibilities: Yes, to oversee other Claims staff

Reports to: Director, Medical and Assistance Services

Salary: $70,000

JOB SUMMARY

Responsible for developing and maintaining a Claims Quality Assurance program that complies with all applicable regulations, governing specifications, and program requirements. Ensures that claims processing and adjudication procedures are conducted according to commonly accepted insurance standards and consistent with DSI contractual obligations.

RESPONSIBILITIES

· Designated liaison with the carrier (AIG/US Life/NUFIC/AIG Canada) for compliance and quality issues.

· Designated liaison with the AGI Actuary for claims data reporting.

· Ensure that claims processing and adjudication procedures and time frames are consistent with DSI contracts, with a quarterly report on any specific shortfalls.

· Lead all primary insurance subrogation efforts, generate a quarterly report of all recoveries, and make recommendations regarding claims that require elevation to legal recourse or possible write-down.

· Identify international providers who appear to be suitable candidates for DAN’s preferred provider network and initiate contact once approved.

· Initiate member contact when grounds exist to believe that they are holding an insurance company payment they are not entitled to and recommend the preferred payment recovery process.

· Point of contact when DAN or DSI is notified of a legal matter involving DAN members, providers, or related third parties; coordinate communication with DAN and carrier, as the situation dictates.

· Provide medical billing and insurance claims recovery assistance to international preferred providers in the Hyperbaric Partners, Ltd. Network of hyperbaric chambers.

· Perform any other related duties as directed by the manager.

MINIMUM QUALIFICATIONS

· Bachelor’s degree or 10 years’ experience in customer service or a related field.

· Proficiency with MS Office® software.

· Excellent telephone etiquette and communication skills.

· Self-motivated with strong attention to detail and problem-solving skills.

· Manages timelines and milestones to meet project deadlines.

Job Type: Full-time

Pay: $70,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• 8 hour shift

Work setting:

• In-person
• Office

Ability to Commute:

• Durham, NC 27705 (Required)

Ability to Relocate:

• Durham, NC 27705: Relocate before starting work (Required)

Work Location: In person

Salary : $70,000