Claims Quality Control Auditor

The Claims Quality Control Auditor ensures organizational claim processing complies with contractual and regulatory requirements. The position performs audit functions for “internal and external” clients, provides training standards based on findings; creates statistical auditing reports for management; identifies trends and potential issues with claims processing, and recommends process improvements to maximize accuracy.

Duties and Responsibilities Responsibilities include, but are not limited to the following:

Review Neighborhood’s claim process functions, including auto adjudicated and manually processed claims and issues, based on provider and health plan contractual agreements and claims processing guidelines.

Adhere to internal processes/procedures that ensure claim auditing functions comply with company policies and procedure standards.

Identify trends and patterns in errors and issues found during audit reviews and upchannel to appropriate management.

Prepare written reports on audit findings, scores and corrective actions.

Advise and assist external departments with claims research and processing issues.

Identify root cause for claim errors, and collaborate with internal and external departments to develop and implement solutions for resolution of identified issue

Review post impact analyses provided by Operations Support to ensure systems upgrades have been configured accurately. Provide written report to Business Analysts of review results. Review any problems found with appropriate Business Analyst.

Create Master Impact Analysis (IA) for each processing system. This Master IA will be created from results of the weekly Claims Adjustment Committee meeting and be used by adjusters from each delegate to reprocess claims according to the respective configuration changes in each system.

Participate in User Acceptance Testing (UAT). As such, perform analysis and review all upgrade information to ensure accuracy and completeness negating any future claims processing issues. Identify any errors in claims processing during this testing and provide input to the configuration teams involved.

Complete any ad-hoc audits that approved by Claims management that are requested by upper management, legal, contracting, or any other party within Neighborhood.

Identify and communicate ways to improve claims and systems processing accuracy and increase provider/member satisfaction.

Report claims with suspected fraud, waste and abuse to management, and submits referrals to Special Investigation Unit.

Other duties as assigned

Qualifications

Required:

Associates Degree or equivalent relevant work experience in lieu of a degree

Minimum 1-3 years directly related experience in medical billing or claim processing

Capable of performing mathematical functions (i.e., calculations/discounts/interest commission/percentages, etc.)Intermediate to Advanced skills in Microsoft Office Suite (Excel, Outlook, Word)
Data analytics experience

Ability to read understand and apply contract terms to claims processing and quality audits

Excellent communications skills allowing for the effective description of systems deficiencies and processing errors

Ability to work both independently and in a team-based environment

Ability to manage multiple projects simultaneously

Must exercise excellent judgment and be effective working autonomously and as part of a team Exceptional listening skills and verbal/written communication skills

Problem solver with strong attention to detail

Preferred:

Certified Professional Coder (CPC) certification3+ years directly related experience in medical billing or claim processing

Knowledge of COGNOS reporting environment

Prior experience with Optum Encoder or similar coding program/websites

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.