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Claims Quality Assurance Specialist

2 months ago

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

Job Summary

HealthCare Resolution Services is seeking a highly skilled Claims Quality Assurance Specialist to join our team. As a Claims Quality Assurance Specialist, you will be responsible for conducting thorough audits of medical and dental claims processed by medical care administrators.

Key Responsibilities

  • Conduct virtual audits of claims processed by medical care administrators to ensure compliance with insurance policies and regulations.
  • Review and validate claim data to ensure accuracy and completeness.
  • Verify that claims are processed in accordance with utilization review decisions and that cost-sharing features of the benefit plan are correctly applied.
  • Ensure that claims are not paid twice and that payments are coordinated correctly if there is other coverage available.
  • Verify that claims are processed in accordance with internal policies and procedures and that sufficient documentation is included in the file to support the adjudication of the claim.

Requirements

  • Bachelor's degree in accounting, finance, or a related field such as health information management.
  • At least three years of experience as a claims auditor or similar role in the healthcare industry.

Preferred Qualifications

  • Strong analytical and problem-solving skills.
  • Excellent attention to detail.
  • Ability to communicate complex information effectively and clearly.
  • Good understanding of insurance policies and regulations.
  • Proficiency in using computer software such as Microsoft Office Suite.

Personal Attributes

  • Ability to work independently and in a team environment.
  • High level of integrity and ethical behavior.
  • Strong organizational and time-management skills.
  • Flexible and adaptable to change.