Claims Analyst jobs in Gainesville, FL

Scope of position: The Claims QA Analyst conducts audits of AvMed, Delegated Vendors, and Business Process Outsourcing (BPO) claims. The Claims QA Analyst conducts claims audits and works closely with the BPO to identify and correct any audit findings

Essential Job Functions:

• Performs audits, analyzes system errors, identifies problems, and initiates corrective actions and preventative actions to ensure quality standards are in compliance with Federal and State regulations (CMS, DOI, AHCA, etc.) and AvMed policies and procedures. Coordinates with BPO and Delegated Vendors to finalize audit findings. Works with NTT to identify system errors and ensure that errors and claims impacted are corrected.
• Applies quantitative and qualitative analysis, maintains data integrity, and conducts quality improvement studies to support decision making, barrier analysis and implementation of interventions. Reviews any vendor initiatives established to ensure appropriate handling and compliance prior to development and implementation. Makes recommendation to Manager for approval.
• Conducts system testing, troubleshooting, implementation, and provides support to ensure business requirements are satisfied and configuration is accurate in contract and benefit configuration. Conducts random audit samples of manually and auto-adjudicated claims with an emphasis on claims payment and processing accuracy.
• Represent Manager in meetings.
• Provides with comprehensive claims analysis to management.
• Provides feedback on current procedures for efficiency and accuracy and assist supervisor in identifying additional training needs as result of their audit findings.
• Performs additional duties and responsibilities as assigned by management.

You have:

• Associates required
• Bachelor's in health sciences or similar concentration preferred
• 6-10 years of experience in a complex managed care environment with multiple products and entities, with an emphasis in claims, pricing and/or benefits. Previous audit or system configuration experience preferred
• An equivalent combination of education and experience may be considered

You May Also Have:

• Strong verbal and written communication skills
• Strong analytical and interpretative skills
• Excellent organizational skills
• Effective problem-solving skills and ability to handle simple and complex tasks
• Detail-oriented skills to adapt to various workflows, multiple tasks, deadlines and changing priorities
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• HRP, MACESS, or Similar Software Systems
• Microsoft Office Suite (Word, Excel, Access)

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• Microsoft Office