Claims Quality Assurance Analyst
2 weeks ago
The Community Health Center Network (CHCN), a key partner of the Alameda Health Consortium, encompasses a network of eight federally qualified community health centers located in Alameda County. CHCN operates as the managed care MSO for these health centers, engaging with the Alameda Alliance for Health. To facilitate the health centers in providing exceptional care to their communities, CHCN delivers training, technical support, quality enhancement, information technology, and data analysis services.
Position Title: Claims Quality Assurance Analyst
Department: Claims
Reports To: Claims Manager
Classification: Non-Exempt
Status: Full-Time, Remote
POSITION SUMMARY
The Claims Quality Assurance Analyst is tasked with the precise processing of specialty, ancillary, primary care provider (PCP), and emergency/urgent care (ER/UC) claims through thorough review and daily auditing. This role includes the development and delivery of training programs based on audit outcomes.
KEY RESPONSIBILITIES
- Oversee claim accuracy utilizing knowledge of benefit packages and utilization standards
- Engage in Claims Department initiatives to improve workflow efficiency
- Provide constructive feedback to claims examiners derived from audit results
- Lead the health plan claims auditing process
- Prepare comprehensive Health Plan audit reports
- Conduct EZCAP testing for new plan benefits and system upgrades
- Evaluate quality trends and recommend actionable solutions
- Assist with inquiries from customer care
- Revise and update Policies & Procedures for the Claims Department
MINIMUM QUALIFICATIONS
Core Competencies
- In-depth knowledge of PCP, Specialty, Ancillary, ER, and Facility claims processing
- Excellent written and verbal communication abilities
- Proficient in CPT and ICD-10 coding
- Highly organized and self-motivated, with a collaborative work ethic
- Capable of prioritizing and managing multiple projects efficiently
Essential Requirements
- A minimum of two to four years of experience in medical claims processing
PHYSICAL DEMANDS
The employee may occasionally lift and/or move up to 15 pounds and might be required to stand, walk, reach, stoop, kneel, or crawl. Specific vision abilities required for this position include close vision and the ability to adjust focus.
WORKING CONDITIONS AND ENVIRONMENT
While executing job responsibilities, the employee is typically exposed to both indoor and outdoor environments.
The Community Health Center Network is an Equal Opportunity Employer.
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