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Claims Quality Assurance Specialist

2 months ago

Columbia, Maryland, United States HealthCare Resolution Services Full time
Job Overview

Position Summary:
This role involves conducting thorough audits of medical and dental claims processed by healthcare administrators. The audits will focus on ensuring compliance with established guidelines and verifying the accuracy of claims.


Key Responsibilities:

  • Review and validate claimant eligibility based on administrator's records.
  • Ensure correct determination of provider network participation for the service dates.
  • Assess claims requiring utilization review to confirm adherence to established decisions.
  • Evaluate the application of deductibles, coinsurance, and other cost-sharing features of benefit plans.
  • Verify the accuracy of claim data entry, whether through manual or electronic submission.
  • Check for other coverage availability and ensure proper coordination of payments.
  • Confirm the correct application of reasonable and customary charges or provider discounts.
  • Ensure that claims are not duplicated in payment.
  • Validate that billed procedures are covered by the plan and free from fraudulent activity.
  • Review mathematical computations for accuracy.
  • Confirm the appropriate application of pre-authorization limits.
  • Ensure that paper claim forms are completed correctly and signed by necessary parties.
  • Adhere to internal policies and procedures during claim processing.
  • Apply necessary approvals for high-value claims.
  • Ensure sufficient documentation supports the adjudication process.

Qualifications:

  • Bachelor's degree in accounting, finance, or a related field such as health information management.
  • A minimum of three years of experience in claims auditing or a similar capacity within the healthcare sector.

Required Skills:

  • Strong analytical and problem-solving capabilities.
  • Exceptional attention to detail.
  • Effective communication skills for conveying complex information.
  • Solid understanding of insurance policies and regulations.
  • Proficiency in Microsoft Office Suite and other relevant software.

Personal Attributes:

  • Ability to work independently as well as collaboratively within a team.
  • Demonstrated integrity and ethical conduct.
  • Strong organizational and time management skills.
  • Adaptability to changing environments.