JOB SUMMARY

The Claims Quality Review Auditor is HYBRID position accountable for auditing various claims to ensure quality and accuracy to related benefit payments, contract interpretation, and compliance with policies and procedures and regulatory guidelines. Makes recommendations to improve quality, workflow processes, policies and procedures.

ESSENTIAL FUNCTIONS OF THE ROLE

• Tracks and trends audits in an effort to identify root cause errors to providers; provides feedback.
• Ensures that the department's procedural manuals consistently help adherence to regulatory guidelines, internal policies and procedures related to claims processing and departmental accuracy standards related to claims payment.
• Develops practical recommendations to management to improve control processes to safeguard assets and improve the efficiency and effectiveness of operations.
• Works to effectively and professionally resolve any discrepancies in claims payments with other departments.
• Audits claims data to calculate claim adjudicator and system accuracy, and completes statistical reports on findings to record audit activity and recommendations.
• Communicates significant audit findings to management. Reports areas of non-compliance to management.
• Prepares and submits detailed audit reports to management to aid in the training/education of staff.

KEY SUCCESS FACTORS

• An Associates Degree or equivalent formal training program preferred.
• Must have experience with Microsoft Word, Excel, and HealthRules software.
• Excellent written/verbal communication and interpersonal skills required.
• Must have the ability to maintain strict confidentiality at all times.
• Exercises good judgment, attention to detail, integrity, dependability, objectivity, and proven statistical skills.
• Demonstrates a working knowledge of good internal controls.

BENEFITS

Our competitive benefits package includes the following

• Immediate eligibility for health and welfare benefits
• 401(k) savings plan with dollar-for-dollar match up to 5%
• Tuition Reimbursement
• PTO accrual beginning Day 1

Note: Benefits may vary based on position type and/or level

QUALIFICATIONS

• EDUCATION - H.S. Diploma/GED Equivalent
• EXPERIENCE - 3 Years of Experience