Quality Assurance Coordinator - Trainer

Responsibilities

• Prepare productivity, status, solicited and unsolicited analysis reports requiring the selection of data from records
• Audit refunds from Department staff to providers to ensure request is valid, and appropriate monies are returned to providers
• Review and determine that billing statement from outsource vendors to commission payments is correct, or specific charges should be removed. Process refunds through the process of Oracle-working with Upper Management, MMO and the Finance Department to ensure checks to Providers are generated and mailed
• Research, troubleshoot and respond to online and written inquiries on over payments activity from outsource vendors and Providers, communicating and collaborating with other functional areas of the Funds
• Confirm existence of over payments and verify amounts recoverable –for Optum refunds.
• Report audit findings of technical QCR’s to QA and Recovery Supervisors. Provide Sr. Manager and Supervisors with feedback ensuring that staffs job duties are performed in an adequate manner and the Department’s standard and quality is maintained
• Review checks received from Optum, update notes and give final approval for deposit of checks received to the Finance Department
• Recovery for staff claims;
  Research and analyze Solicited/Unsolicited refund request before sending Refund Letters
• Review and update all refunds received, scan documents in QNXT and DMS Recovery System.
• Create Provider Advance and respond to Provider inquiries
• Review claim history from Optum cited over payments to identify additional over payments and forward it to the Recovery Unit for refund request or request reports to be run internally identify and request refunds
• Obtain proper documents for refunds returned to Providers including W-9 and letters from providers requesting money
• Perform backup functions for Recovery/Quality Assurance Supervisors, ensuring adequate coverage of critical functions (and Monthly Reports are generated timely)
• Perform administrative support functions including Ordering supplies, filing, maintaining Sr. Manager’s calendar; facilitate managing of the office
• Stay current with Staff Claims Monthly reports
• Assist and provide staff and their supervisors with any claims-related issues
• Offer support to QA and Recovery staff as needed
• Assist Organizational Development Training and Learning (ODTL) with staff training and testing whenever updates or training are required for QNXT
• Perform additional duties and special projects as assigned by Management

• High School Diploma or GED required College Degree preferred; or the equivalent years of experience required
• Minimum two (2) years experience in the Health Care insurance or benefit environment required
• Perform administrative support functions including arranging disbursements to outsource vendors and providers
• Coordination of benefits (COB), claim processing, medical terminology, and systems (QNXT)
• Proficiency in Microsoft Word and Excel; strong overall computer skills preferred;
  Basic knowledge required
• Excellent problem solver with excellent analytical skills
• Able to work well under pressure, multi-task, establish priorities, meet deadlines, and follow through on assignments
• Excellent oral and written communication skills
• Strong organizational skills
  
  Ability to work independently and be a team player