Quality Control Reviewer

RESPONSIBILITIES

• Review, manage and triage daily mail intake, including appeals email inbox, to ensure all necessary documentation is complete and accurate, independently determine priority and distribute appeals and inquiries to Appeals staff via Document/Appeals Management System (DMS/AMS) per existing workflow.
• Assist with the research of new appeals/inquiries by accessing QNXT, medical/hospital claims systems, provider, and V3 (Vi-Tech) to verify member’s eligibility, demographics, provider records, and claims.
• Document and update accurate memos of incoming/outgoing correspondence regarding appeals and inquiries and communications in claims processing system (QNXT) and DMS/AMS.
• Maintain accurate and detailed records of mail and track assignments via tracking logs/reports to ensure all assignments are handled timely in accordance with departmental policies and procedures.
• Review and respond to provider inquiries and ensure that they are sent to the appropriate payment area for benefit reconsideration; track and ensure completeness.
• Communicate with members and providers via phone and in writing to obtain necessary information and address appeal‑related questions.
• Provide assistance with respective workflows to Appeal Reviewer’s.
• Retrieve messages from Appeals Hotline, including callbacks, and maintain log report.
• Index and archive documents/files electronically in DMS/AMS.
• Conduct system testing related to departmental system enhancements and review performance of automated software.
• Perform additional duties and projects assigned by management.

• High School Diploma or GED required.
• Minimum two (2) years clerical experience in a health‑plan environment and one (1) year customer‑service experience required.
• Knowledge of medical claims processing including major medical, office visits, surgery, anesthesia, lab and x‑rays required.
• Knowledge of eligibility systems including Coordination of Benefits (COB) and Consolidated Omnibus Budget Reconciliation Act (COBRA) benefits required.
• Knowledge of QNXT claims and provider system with the ability to effectively and efficiently check medical and hospital claims history and provider participation records required.
• Understanding of benefit program and eligibility guidelines, including eligibility verification, of the 1199
  
  SEIU Benefit and Pension Funds required.
• Knowledge of web‑based applications, ability to learn and use computer databases and online filing systems preferred.
• Excellent oral and written customer‑service skills and ability to maintain a pleasant attitude; provide professional and courteous service to members.
• Analytical, detail‑oriented, ability to work under pressure independently and as a team player; ability to prioritize, follow up, and handle multiple tasks based on set time frames and organizational skills.
• Intermediate skill level in Microsoft Word and Excel preferred.
• Must be able to maintain the confidentiality required by the organization and the department.
• Must meet performance standards, including attendance and punctuality.