Quality Control Reviewer II

Responsibilities

• Monitor claims processing system (QNXT) to ensure functionality of Hospital claims processing (i.e electronic, imaging, eligibility downloads from V3, pricing verification and pay-to-assignments)
• Ensure timely/accurate processing of hospital claims according to Claims Xten, Lab Management, Radiation Therapy, High-End Imaging, Medical Oncology and Specialty drug programs (i.e eviCore and Care Continuum);
  Summary Plan Description (SPD) guidelines, member benefits/eligibility parameters pre-authorization requirements;
  Fund policies and contracted/repricing rates
• Conduct system testing as it relates to QNXT upgrades, system enhancements and review performance of automated software
• Review Document Management System (DMS) inquiries/reconsiderations/medical records for accuracy, claims spreadsheets and determine action needed to rectify and resolve claims
• Respond in writing to provider inquiries/reconsiderations regarding claim adjustments/denials
• Resolve call tracking tickets and escalated e-mails in a timely manner
• Perform adjustments (related to inquiries, Med Review focused/revised DRGs Care Allies retrospective determinations); request credit refunds from provider and members; update member/claim memos regarding payment adjustments (over payments and refunds)
• Request refunds for erroneous payments from providers and members
• Process and evaluate facility claims manually or through DMS
• Apply over payments and refunds received and reported by the Claims Quality Assurance Department
• Resolve complex issues involving: 1st and 2nd level appeals
• Perform additional duties and projects as assigned by management

• High School Diploma or GED required, some College or Degree preferred
• Minimum (2) two years hospital claims processing experience required
• Strong knowledge of eligibility system, Coordination of Benefits (COB) guidelines and hospital claims processing required
• Intermediate knowledge of Microsoft Excel required; MS Word preferred
• Excellent communication skills both oral and written required; able to initiate correspondence and respond to inquiries in a clear and professional manner
• Ability to prioritize and work under pressure, with strict timelines and target dates
• Strong organizational and analytical skills with the ability to multi-task and follow up
• Good problem-solving skills with the ability to work independently and be a team player