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Claims Quality Assurance Analyst
2 months ago
Organizational Overview
The Community Health Center Network (CHCN) is a collaborative organization associated with the Alameda Health Consortium, encompassing eight federally qualified community health centers in Alameda County. CHCN operates as the managed care MSO for our health centers, engaging with various health plans to ensure optimal care delivery within our communities. We provide extensive training, technical support, quality enhancement, information technology, and data analysis services to empower our health centers in their mission.
Position Title: Claims Quality Assurance Analyst
Department: Claims Management
Reports To: Claims Manager
Classification: Non-Exempt
Status: Full-Time, Remote
Location: Candidates must reside in California.
POSITION SUMMARY
The Claims Quality Assurance Analyst is tasked with the precise evaluation and processing of various categories of claims, including specialty, ancillary, PCP, and ER/UC claims, through comprehensive reviews of internal audits, health plan audits, and state audits. This role also involves developing and delivering training for claim examiners based on audit outcomes.
KEY RESPONSIBILITIES
The following responsibilities are typical for this position and are not intended to be an exhaustive list of all duties:
- Oversee the accuracy of processed claims utilizing in-depth knowledge of benefit packages, utilization protocols, and financial responsibility divisions.
- Lead the complete audit process for health plan claims.
- Generate various audit reports as required.
- Conduct internal audits focusing on claim examiners.
- Provide constructive feedback to claim examiners based on audit results, both individually and in group settings.
- Train team members on claims processing and workflow adjustments resulting from updates and audit findings.
- Analyze quality trends and propose effective solutions.
- Manage check run reports and execute the check run process as designated.
- Conduct EZCAP testing and monitoring for new plan benefits and system upgrades.
- Investigate and resolve escalated claims inquiries, engaging with provider offices as necessary.
- Review all types of claims, leveraging comprehensive knowledge of benefit packages and utilization guidelines.
- Assist in refining workflows and updating departmental policies and procedures.
- Perform additional duties as assigned.
QUALIFICATIONS
Competencies:
- Expertise in processing PCP, specialty, ancillary, ER, and facility claims within an MSO/IPA framework.
- Familiarity with CPT and ICD-10 coding.
- A minimum of two to four years of relevant experience in an MSO/IPA environment.
Essential Attributes:
- Self-motivated individual with a proactive approach to problem-solving, capable of managing multiple projects and meeting deadlines.
- Strong communication skills, fostering open dialogue with team members, internal clients, and stakeholders.
- Collaborative team player who enhances team dynamics and contributes positively.
- Exceptional written and verbal communication skills, facilitating effective interactions at all organizational levels.
PHYSICAL DEMANDS
The physical requirements outlined here are representative of those that must be met by an employee to successfully perform the essential functions of this role. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.
While fulfilling the duties of this position, the employee is regularly required to sit and utilize hands for various tasks. The employee frequently engages in verbal communication and may need to stand, walk, reach, or perform other physical activities. Occasionally, the employee may lift or move items weighing up to 15 pounds. Specific vision abilities required for this role include close vision and the ability to adjust focus.
WORKING CONDITIONS AND ENVIRONMENT
The work environment characteristics described here are representative of those an employee may encounter while performing the essential functions of this role. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.
While executing the responsibilities of this position, the employee is regularly exposed to an indoor environment.
The Community Health Center Network is an Equal Opportunity Employer.
