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Sr Claims Quality Assurance Analyst

2 months ago

Houston, United States Harris Health Full time

JOB SUMMARY
To review claims for new hires, experienced Examiners and auto adjudicated claims in a timely and consistent manner. Generate accuracy reports per processor to be reviewed by operations management and senior management staff. Senior Claims Quality Assurance Analyst will be responsible for trending and root cause analysis and providing a clear and concise report to the management staff. Senior Claims Quality Analyst will be responsible for reviewing and responding to all first level appeals. Senior Claims Quality Analyst responsibility will include mentoring Examiners and Quality Analyst as requested. Responsibilities also include the review and audit of the Provider Communication, Provider Fee Schedule, and Provider Database team.

JOB SPECIFICATIONS AND CORE COMPETENCIES

Perform 3% random audit on all claims processed post check disbursementPerform 100% audit on all zero pay claims with a billed amount of $10,000 or greater pre-check disbursementPerform 100% audits of all claims paying $10,000 or greater pre-check disbursementProduction of 12 audits per hour with 97% technical, 98% financial and 98% accuracy.Facilitate a weekly calibration meeting. Conduct trending and root cause analysis; provide feedback to the examiners and quality analyst based on these findings. Alert Trainer of retraining issues identified by audit of claims and adjustments.Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans.Performs other duties as assigned.


MINIMUM QUALIFICATIONS:

Education/Specialized Training/Licensure: High school Graduate or GED equivalentWork Experience (Years and Area): 5 years in claims adjudication, with a minimum four-year auditing experienceManagement Experience (Years and Area): N/ASoftware Proficiencies: PC, 10 key skills, medical coding, CPT and HCPC coding

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