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Claims Quality Oversight Analyst

Claims Quality Oversight Analyst

EmblemHealthNew York, NY, United States
Hace 13 horas
Tipo de contrato
  • A tiempo completo
Descripción del trabajo

Summary of Position

  • To oversee the performance of vendors who are delegated for the claims processing function to ensure delegates meet and are aligned with EH standards.
  • Accountable to perform quality assurance oversight of delegated vendors and administer EH Delegated Vendor Oversight Committee (DVOC) annual audits of the delegated arrangements.

Job Responsibilities

  • Administer audits of the delegate claims processing function :
  • Request supporting documentation for randomly selected samples of delegate processed claims.
  • Work with the RM to ensure that all delegate-provided information is complete prior to commencement of audit.
  • Review all documentation and populate DVOC audit tool with claims detail for all selected samples.
  • Review delegate's Claims policies & procedures and score the DVOC audit tool for completeness.
  • Conduct exit conference with delegates to discuss audit findings.
  • Share findings with delegate and review disputes.
  • Prepare all applicable audit memos for presentation to the DVOC (audit memo, CAP and CAP updates memos)
  • Administer CAPs and monitor to ensure that the corrective plans are completed and tested within timeline.
  • Meet with delegates to discuss areas of concern in the timely resolution of identified issues.
  • Work closely with RMs to obtain supporting documentation to support delegate's confirmation of resolution.
  • Analyze monthly KPI reporting packages received and prepare analysis report to share with delegate for response.
  • Ensure completeness and adherence to claims processing TATs and all other designated claims metrics.
  • Review for trends adversely impacting claims processing quality and highlight in written analysis.
  • Participate in monthly Administrative Operating Committee meetings with delegates to discuss areas of concern within the claims' metrics and status updates on implementation of open corrective actions.

    • Qualifications

  • Bachelor's Degree; additional years of experience / specialized training may be considered in lieu of educational requirements required
  • 2 - 3 years' experience in claims auditing required
  • 1+ years' experience working in BPASS model preferred
  • Strong knowledge of claims processing, procedures and systems, State, Federal and Medicare Regulations required
  • Excellent organizational and time management skills required
  • Extensive knowledge of professional and facility claims processing systems required
  • Strong analytical and deductive evaluation skills to anticipate and resolve potential claim systems discrepancies and the ability to propose effective solutions required
  • Proficiency with MS Office applications (Word, Excel, Access, etc.) required
  • Effective communication skills (verbal, written, presentation, interpersonal) with all types / levels of audiences required

    • Additional Information

    Requisition ID : 1000002803

    Hiring Range : $48,600-$83,160

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