Physical Health Claims Quality Review Analyst (Remote)

Position eligible for –

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs

See attachment for additional details.

Office Location: Flexible for any of our office location; Remote Option Available

Projected Hiring Range: Depending on Experience
Closing Date: Open Until Filled

Primary Purpose of Position:

This position serves as the primary reviewer of professional claims and oversight of claims adjudication quality control activities through continuous monitoring and quality control measures.

Role and Responsibilities:

60% Quality Review

• Oversees post claims adjudication and billing analysis utilizing billing data from various sources; provides weekly and monthly reporting to the Claims Director to report the integrity and quality of Alpha claims and billing system
• Trouble-shoots problems/concerns and facilitates problem solving within waiver adjudication system
• Serves as the backup for submission of Alpha technical issues and tickets
• Serves as a backup for the Claims Director/Supervisor on designated committees
• Audits and reviews Eligibility and Enrollment issues
• Provides backup assistance to the Claims Director/Supervisor as necessary
• Serves as the Primary Reviewer for Timely Filing Requests
• Provides backup assistance for other Claims Analyst and Hospital Quality Review Analyst

40% Compliance and Quality Assurance:

• Monitors event integrity and other activities related to compliance and quality assurance, including trends and analysis of service and adjudication activities through the Alphasystem via routine and random sampling, check write results and audits
• Reports trends and analysis results to the appropriate committees for quality improvement and training to meet performance measures
• Processes and reports dashboard indicators for quality management reporting related to all claims processing and billing functions of the agency
• Performs Tentative Notice of Overpayment reverts
• Oversees 3% Audit claims reviews
• Performs focused reviews of claims for cause and upon request of management
• Monitors Coordination of Benefits audit requests

Knowledge, Skills and Abilities:

• Comprehensive knowledge of claims procedures and methods
• Working knowledge of the Medicaid Waiver requirements, HCPCS, revenue codes, ICD-9/10, CMS 1500/UB04 coding, compliance and software requirements used to adjudicate claims
• Computer proficiency, including the use of Word and Excel programs
• Strong organization skills
• Ability to independently handle daily decision making
• Ability to handle large volume of work and to manage a desk with multiple priorities
• Ability to speak and write professionally
• Ability to work in a team atmosphere and in cooperation with others and be accountable for results
• Ability to read printed words and numbers rapidly and accurately
• Ability to understand oral and written instructions
• Ability to enter routine and repetitive batches of data from a variety of source documents within structured time schedules
• Ability to maintain confidential information

Education and Experience Required:

Associate Degree in Accounting or Business and five (5) years of experience in claims processing in a healthcare setting; or an equivalent combination of education and experience.