Claims Training and Quality Assurance Specialist

1 week ago

Sunrise Manor, Nevada, United States Community Care Plan Full time
Job Title: Claims Training and Quality Assurance Specialist

Community Care Plan is seeking a highly skilled Claims Training and Quality Assurance Specialist to join our team. As a Claims Training and Quality Assurance Specialist, you will be responsible for overseeing and conducting various testing activities related to contract validation, benefit engine functionality, fee schedule accuracy, and other IT-driven initiatives within the claims processing environment.

Key Responsibilities:
  • Conduct thorough contract testing to validate parameters and ensure compliance with contractual agreements.
  • Perform benefit engine testing to verify the accuracy and functionality of claims processing systems in alignment with plan specifications.
  • Test fee schedules to ensure accuracy and compliance with regulatory guidelines and provider contracts.
  • Collaborate with IT teams to participate in user acceptance testing (UAT) and regression testing for system upgrades and implementations.
  • Conduct claims audits to review processed claims for accuracy, completeness, and compliance with regulatory and organizational standards.
  • Identify trends, patterns, and potential issues through auditing processes, and provide recommendations for process improvements.
  • Analyze testing results and audit findings to identify discrepancies, trends, or areas for improvement in claims processing.
  • Investigate root causes of errors or issues identified during testing or auditing, and collaborate with IT and business teams to implement corrective actions.
  • Document testing procedures, audit findings, and resolutions to maintain comprehensive records and support continuous improvement efforts.
  • Ensure compliance with healthcare regulations (e.g., HIPAA, CMS guidelines) and internal policies during testing, validation, and auditing processes.
  • Implement quality assurance measures to uphold standards of accuracy, efficiency, and regulatory compliance in claims processing activities.
  • Provide training and guidance to claim examiners or new team members on testing methodologies, claims auditing processes, and best practices.
  • Develop training materials and resources to enhance the knowledge and skills of team members in claims processing, compliance, and quality assurance.
  • Conduct regular training sessions to ensure team members are up-to-date with industry trends, regulatory changes, and organizational policies.
  • Maintain detailed documentation of testing procedures, audit methodologies, findings, and recommendations for future reference and audit purposes.
  • Communicate effectively with cross-functional teams to convey testing and auditing findings, collaborate on solutions, and drive operational enhancements.
  • Collaborate with subject matter experts (SMEs), department managers, and stakeholders to identify training needs and objectives.
  • Facilitate training sessions through various mediums (e.g., classroom training, workshops) to educate employees on claims processing procedures, policies, and regulatory requirements.
  • Collaborate with department managers, to address training needs and align training initiatives with organizational goals.
  • Provide support and guidance to claims processing staff on complex claims cases or procedural inquiries.
  • Thorough knowledge of coding structures (CPT, HCPCS, Revenue codes, ICD10, DRG etc.)
  • Adjudicate claims based on established policies, guidelines, and fee schedules, making determinations on claim eligibility, coverage, and reimbursement.
  • Investigate and resolve discrepancies, errors, and discrepancies in claim submissions, collaborating with Claim Analysts as needed.
  • Maintain detailed records of claim processing activities, including correspondence, payment authorizations, audit trails and Claim notes.
  • Provide courteous and professional assistance to internal customers, and other stakeholders regarding claim inquiries, appeals, and disputes.
  • Stay updated on changes in healthcare regulations, coding guidelines, and industry best practices through.
  • Processes claim corrections and COB updates via interdepartmental customer relationship management process.
  • Complete side by side and peer training as necessary for educational opportunities.
  • Assists with projects and clerical support as needed.

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