Claims Quality Assurance Specialist

2 weeks ago

Chula Vista, California, United States Community Health Group Full time
Job Overview

POSITION SUMMARY

The Claims Quality Assurance Specialist is responsible for enhancing and sustaining the precision and quality of claims processed by Community Health Group. This role involves conducting thorough pre-disbursement evaluations for fee-for-service claims. The specialist will gather, monitor, and analyze audit outcomes, while also proposing training initiatives and other enhancement strategies.

REGULATORY COMPLIANCE

This position requires close collaboration with various departments to ensure that all processes, programs, and services are executed efficiently and in alignment with CHG policies, as well as adhering to relevant state and federal regulations.

KEY RESPONSIBILITIES

  • Perform pre-disbursement evaluations (quality assessments) of selected claims, providers, or processes, including interest payments, misdirected claims, and auto-adjudicated claims.
  • Examine data to detect processing mistakes, improper billing practices, and potential fraudulent activities related to services rendered.
  • Serve as a backup for the VE Claims Auditors, executing relevant functions associated with this role.
  • Offer suggestions for staff training based on irregularities identified during the claims evaluation process.
  • Present recommendations for provider training and other necessary actions based on audit results.
  • Analyze information from diverse sources and produce weekly, monthly, and quarterly trend reports.
  • Review all claims with payment amounts exceeding $5,000 for Professional claims and $10,000 for Hospital claims.
  • Identify discrepancies, billing errors, and system configuration challenges, reporting these to the Claims Audits Supervisor for further investigation.
  • Complete tort liability documentation, compiling all necessary Third Party Liability claims data for submission to the Department of Health Services, Third Party Liability Division.
  • Uphold the organization's reputation and contribute to team objectives by maintaining a professional demeanor, participating in committees and meetings, and performing additional duties as assigned.

Qualifications

EDUCATION

  • Associate's degree
  • Certification in coding and/or medical terminology

EXPERIENCE/ SKILLS

  • At least five years of experience in claims analysis and processing
  • In-depth knowledge of Medi-Cal and Medicare payment regulations
  • Strong background in healthcare and managed care
  • Extensive expertise in claims coding and auditing
  • Clear understanding of medical record evaluations
  • Ability to manage confidential and sensitive information with discretion
  • Proficiency in Microsoft Office Suite
  • Exceptional verbal, written, organizational, and analytical abilities

PHYSICAL REQUIREMENTS

  • Extended periods of sitting

Community Health Group is an equal opportunity employer committed to fostering diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and training. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs.

  • Quality Assurance Specialist

    2 weeks ago

    Chula Vista, California, United States BIO FILM INC Full time

    About BioFilm IncCompany OverviewBioFilm is a manufacturer and distributor of premium medical device and personal care products dedicated to enhancing consumer well-being. Our flagship offering, ASTROGLIDE, stands as a leading brand in the personal lubricant market. Based in Vista, CA, our operations encompass sales, marketing, consumer engagement, research...

  • Quality Assurance Specialist

    2 weeks ago

    Chula Vista, California, United States BIO FILM INC Full time

    About BioFilm IncCompany OverviewBioFilm Inc is a prominent manufacturer and distributor of premium medical devices and personal care products, dedicated to enhancing the well-being of our customers. Our flagship product, ASTROGLIDE, stands as a leading brand in the personal lubricant market. Our corporate headquarters is located in Vista, CA, where we house...

  • Senior Quality Assurance Specialist

    2 weeks ago

    Chula Vista, California, United States General Dynamics Information Technology Full time

    Position Overview:As a Senior Quality Assurance Specialist, you will engage in a comprehensive range of quality assessment activities on products, materials, and components throughout various phases of the manufacturing process to ensure adherence to quality and reliability benchmarks.Key Responsibilities:Conducts diverse quality control evaluations and...

  • Quality Assurance Specialist

    5 days ago

    Chula Vista, California, United States Chili's Grill & Bar Full time

    About the RoleWe are seeking a highly skilled Quality Assurance Specialist to join our team at Chili's Grill & Bar. As a Quality Assurance Specialist, you will play a critical role in ensuring that every guest receives perfectly prepared, high-quality food.Key ResponsibilitiesFood Preparation and Quality Control: Ensure that food is prepared to company...

  • Nondestructive Testing Quality Assurance Specialist

    2 weeks ago

    Chula Vista, California, United States General Dynamics Information Technology Full time

    Type of Requisition:RegularClearance Level Must Currently Possess:NoneClearance Level Must Be Able to Obtain:SecretSuitability:Public Trust/Other Required:NoneJob Family:SCAJob Qualifications:Skills:Magnetic Particle Inspection (MPI), Nondestructive Testing (NDT), Quality Assurance (QA)Certifications:Experience:0 + years of related experienceUS Citizenship...

  • Director of Clinical Operations and Quality Assurance

    5 days ago

    Chula Vista, California, United States GLIA HEALTH MANAGEMENT LLC Full time

    Job DescriptionThe Director of Clinical Operations and Quality Assurance is a key leadership position at Glia Health Management LLC, responsible for overseeing the day-to-day activities and development of our clinics. This role ensures that our organization is managed and performing efficiently and effectively, with a focus on delivering high-quality patient...

  • CNC Quality Assurance Supervisor

    1 week ago

    Chula Vista, California, United States Western CNC Full time

    Position Overview: CNC Quality Assurance SupervisorWe are a dynamic and large-scale CNC machining facility looking for a committed Quality Assurance Supervisor to oversee our quality control processes.Key Responsibilities:Perform first article inspections, in-process evaluations, and final assessments of both machined components and sourced...

  • Medical Biller/Coder Specialist

    4 days ago

    Chula Vista, California, United States CRA MSO LLC Full time

    Job Opportunity at CRA MSO LLCJob Summary:We are seeking a highly skilled and experienced Medical Biller/Coder Specialist to join our team at CRA MSO LLC. As a key member of our Revenue Cycle department, you will be responsible for ensuring accurate and timely billing and coding of medical services.Key Responsibilities:Utilize medical billing guidelines and...

  • Medical Claims Auditor

    6 days ago

    Chula Vista, California, United States Community Health Group Full time

    Job SummaryCommunity Health Group is seeking a skilled Claims Auditor to promote and maintain the quality and accuracy rate of claims paid by our organization. The successful candidate will conduct pre-disbursement audits for fee-for-service claims, compile and track audit results, and recommend training and improvement ideas to enhance our claims...

  • Quality Assurance Inspector, Shipyard Operations

    1 week ago

    Chula Vista, California, United States Integrated Marine Services, Inc. (IMS) Full time

    Job OverviewWe are looking for a Quality Assurance Inspector to oversee quality control measures within our operations. The successful candidate will execute quality assessments and inspections in alignment with NAVSEA Standard Items and various technical documentation. You will create Test Inspection Plans (TIP) and verify Test Inspection Records (TIR)...

  • Senior Quality Assurance Specialist

    2 weeks ago

    Chula Vista, California, United States General Dynamics Information Technology Full time

    Type of Requisition:RegularClearance Level Must Currently Possess:NoneClearance Level Must Be Able to Obtain:NoneSuitability:Public Trust/Other Required:Job Family:SCAJob Qualifications:Skills:Electrical Designs, Electrical Installations, Electrical Measurements, Electrical Wiring, Quality Control InspectionCertifications:Experience:3 + years of related...

  • Quality Assurance Associate

    6 days ago

    Chula Vista, California, United States Sunrise Systems Full time

    Job SummarySunrise Systems is seeking a highly skilled Laboratory Technician I to join our team in a reagent/medical device manufacturing facility. As a key member of our assembly team, you will be responsible for the manufacturing of specific chemistries used in the medical diagnostics field.Key ResponsibilitiesBuffer/Reagent Formulation: Mix, adjust pH,...

  • Senior Vice President of Quality Assurance

    2 weeks ago

    Vista, California, United States CLevelCrossing Full time

    Company OverviewThe Swiss-based Group is a publicly traded, innovation-focused organization that excels in the development and production of peptides and oligonucleotides. As a comprehensive service provider, the company offers products for both clinical development and commercial applications, alongside an extensive catalog and specialized custom...

  • Technical Field Service Specialist

    2 weeks ago

    Chula Vista, California, United States Defense Maritime Solutions Inc Full time

    The Technical Field Service Specialist delivers mechanical, electrical, and supervisory expertise to assemble, install, repair, overhaul, and maintain products for Defense Maritime Solutions in accordance with established tolerances and procedures. This role also collaborates with the regional sales team to provide insights and recommendations based on...

  • Technical Field Service Specialist

    1 week ago

    Chula Vista, California, United States Defense Maritime Solutions Inc Full time

    Job OverviewThe Technical Field Service Specialist plays a crucial role in delivering mechanical, electrical, and supervisory support for the assembly, installation, repair, overhaul, and maintenance of products offered by Defense Maritime Solutions Inc. This position is essential in ensuring that all services adhere to specified tolerances and established...

  • Validation Specialist

    7 days ago

    Chula Vista, California, United States Katalyst Healthcares and Life Sciences Full time

    About the RoleKatalyst Healthcares and Life Sciences is seeking a highly skilled Validation Specialist to join our team. As a CSV Engineer, you will play a critical role in ensuring the quality and compliance of our clients' systems and processes.Key ResponsibilitiesProject Management: Collaborate with project managers and client personnel to understand...

  • Raya Insurance Agency: Client Relations Specialist

    1 week ago

    Chula Vista, California, United States Raya Insurance Agency Usmc Full time

    Client Relations Specialist at Raya Insurance AgencyAn excellent opportunity is available for a Client Relations Specialist at Raya Insurance Agency. This entry-level role serves as a stepping stone into a fulfilling career within the dynamic financial services sector. If you are an enthusiastic individual who takes pleasure in assisting others, this...

  • Mechanical Engineering Specialist

    2 weeks ago

    Chula Vista, California, United States VQ Orthocare Full time

    Are you looking for a rewarding technical position in a dynamic work setting? If you enjoy both practical and analytical tasks, this role may be ideal for you. VQ OrthoCare, a leading medical device organization in Southern California, is excited to offer a Mechanical Engineering Specialist position within our Product Development team.Position Overview:The...

  • Claims Processing Specialist

    2 weeks ago

    Chula Vista, California, United States Sunroad Automotive Full time

    Resumen del Trabajo:Los Especialistas en Procesamiento de Reclamaciones aseguran que el concesionario reciba el pago correspondiente por el trabajo de garantía mediante la preparación, presentación y seguimiento de las reclamaciones. Se espera que, al igual que en todas las posiciones dentro de los concesionarios, los Especialistas en Procesamiento de...

  • Provider Relations Specialist

    2 weeks ago

    Chula Vista, California, United States Community Health Group Full time

    Job OverviewPOSITION SUMMARYThe Provider Relations Specialist plays a crucial role in addressing and resolving issues faced by healthcare providers, ensuring they remain informed about relevant policies, procedures, and contractual updates. This position is responsible for coordinating educational initiatives and training for providers while disseminating...