Claims Quality Assurance Specialist

3 weeks ago

New York, New York, United States MetroPlusHealth Full time
MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that healthcare is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

Our organization is dedicated to providing the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens, and Staten Island. We offer a comprehensive list of products, including New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, and more.

As a Claims Quality Auditor, you will be responsible for reviewing claims to determine if payments have been made correctly. This involves analyzing data used in settling claims to determine the validity of payment of claims and reporting overpayments, underpayments, and other irregularities based on benefit configuration, compliance with provider contract agreements, and Federal, State, and Plan's established guidelines and/or policies and procedures.

Key Responsibilities:

* Audit daily processed claims through random selection based on set criteria.
* Document, track, and trend findings per organizational guidelines.
* Determine ongoing Claims Examiner training needs and assist in the development of training curriculum.
* Conduct in-depth research of contract issues, system-related problems, claims processing policies and procedures, etc., to confirm cause of trends. Recommend actions/resolutions.
* Work with other organizational departments to develop corrective action plans to improve accuracy of the claims adjudication processes and assure compliance with organizational requirements and applicable regulations.
* Assist in the development of Claims policies and procedures.
* Provide backup for other trainers within the department.
* Assist in training of new departmental staffs.
* Assist with the research and resolution of audit appeals.
* Assist with external/internal regulatory audits.
* Identify policies or common errors requiring retraining sessions.
* Participate in quality projects as required.

Requirements:

* Associate degree required; Bachelor's degree preferred.
* Minimum of 4 years of experience performing claims quality audits in a managed care setting.
* Expertise in both professional and institutional claims coding, and coding rules required.
* Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology, and standard industry reimbursement methodologies required.
* Strong knowledge of CMS Medicare and NYS regulations required.
* Experience in training development and presentation preferred.
* Must have excellent interpersonal, verbal, and written communication skills.

Professional Competencies:

* Strong organizational, analytical, and oral/written communication skills required.
* Proficiency in PC application skills, e.g., Excel, Word, PowerPoint, etc.
* Must be able to follow direction and perform independently according to departmental guidelines.

If you are a detail-oriented individual with excellent analytical skills and a passion for healthcare, we encourage you to apply for this exciting opportunity.

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