What are the responsibilities and job description for the Claims Quality Analyst position at MetroPlusHealth?
Position Overview
Claims Quality Auditor is responsible for reviewing claims to determine if payments have been made correctly. This position analyzes data used in settling claims to determine the validity of payment of claims and reports overpayments, underpayments and other irregularities based upon benefit configuration, compliance with provider contract agreements, and Federal, State and Plan’s established guidelines and / or policies and procedures. The incumbent will research, review, and suggest process improvements, training opportunities and is a resource of information to all staff. The incumbent will also perform special projects.
Job Description
Audit daily processed claims through random selection based on set criteria.
Document, track, and trend findings per organizational guidelines
Based upon trends, determine ongoing Claims Examiner training needs, and assist in the development of training curriculum.
Conduct in-depth research of contract issues, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends. Recommend actions / resolutions.
Work with other organizational departments to develop corrective action plans to improve accuracy of the claims adjudication processes and assure compliance with organizational
requirements and applicable regulations
Assist in the development of Claims policies and procedures
Provide backup for other trainers within the department
Assist in training of new departmental staffs
Assist with the research and resolution of audit appeals
Asist with external / internal regulatory audits
Identify policies or common errors requiring retraining sessions.
Participate in quality projects as required.
Collect, analyze data, identify trends, write reports (i.e., the monthly and quarterly reports) and present findings to the appropriate claims service management personnel.
Minimum of 4 years of experience performing claims quality audits in a managed care setting
Expertise in both professional and institutional claims coding, and coding rules required.
Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and standard industry reimbursement methodologies required.
Strong knowledge of CMS Medicare and NYS regulations required.
Experience in training development and presentation preferred
Must have excellent interpersonal, verbal, and written communication skills
Professional Competencies
Strong organizational, analytical, and oral / written communication skills required.
Proficiency in PC application skills, e.g., excel, word, PowerPoint, etc.,
Must be able to follow direction and perform independently according to departmental
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