Claims Quality Control Auditor (35027)

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 Neighborhoods claim process functions, including auto-generated adjudicated claims, based on provider and health plan contractual agreements and claims processing guidelines.
• Adheres to internal processes/procedures that ensure claim auditing functions comply with company policies and procedure standards.
• Advises and assists external departments with claims research and processing issues.
• Prepares statistical audit reports on audit findings, scores and corrective actions.
• Document and communicate claim issues identied during QC process and notify appropriate staff.
• Identifies root cause analysis for claim errors, and collaborate with internal and external departments to develop and implement solutions for resolution.
• Monitor claim error corrections reported in the audits.
• Report claims with suspected fraud, waste and abuse to management, and submits referrals to Special Investigation Unit.
• Meets with training department and claims management to recommend training related to QC reporting.
• Other duties as assigned.
• Corporate Compliance Responsibility - Responsible for complying with Neighborhoods Corporate Compliance, Standards of Business Conduct, applicable contracts, laws, rules/regulations, policies and procedures as it applies to individual job duties, the department, and Company. This position exercises due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents