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Claims Quality Assurance Specialist

1 month ago


San Jose, California, United States Santa Clara Family Health Plan Full time

The Claims Quality Assurance Auditor plays a critical role in ensuring the accuracy, consistency, and quality of claims processing at SCFHP. This position requires strong analytical and communication skills, as well as experience in claims processing and auditing.

**Key Responsibilities:**

  • Conduct audits of claims processed against established Plan guidelines and protocols
  • Maintain a broad knowledge of SCFHP Medi-Cal and Medicare claims processing rules and regulations
  • Responsible for maintaining a high level of accuracy and compliance with regulatory requirements
  • Collaborate with Claims Analysts to resolve complex claims issues
  • Provide training and feedback to Claims staff
  • Monitor and oversee claims reports to ensure compliance with claims payment standards

**Requirements:**

  • Associate's Degree in Business, Healthcare, or related field
  • Minimum of five years of claims processing or claims auditing experience
  • Prior experience with managed care plans, Medi-Cal and/or Medicare programs
  • Knowledge of professional and hospital reimbursement methodologies
  • AAPC Certified Professional Coder (desired)

**Working Conditions:**

  • Primarily performed in an office environment
  • Frequent contact with and interruptions by co-workers, supervisors, and plan members or providers
  • Regular bending, reaching, and sitting or standing for extended periods

SCFHP is a leading health plan dedicated to providing high-quality care to its members. This position offers a unique opportunity to work with a talented team and contribute to the success of the organization.