Quality Claims Analyst

About the position

The Quality Claims Analyst will assist the Director of Member Engagement in all areas of claim payment monitoring. The Quality Claims Analyst will conduct daily audits of processed claims and assist with other program audits as deemed appropriate by the department manager.

Responsibilities

• Assist in the development and implementation of auditing and monitoring mechanisms
• Helps to evaluate the adjudication of claims using standard principles and State specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims.
• Prepares, tracks and provides audit findings reports according to designated timelines.
• Participates in the review of claims and member eligibility information to uncover claims overpayment trends associated with non-compliance or misapplication of contract terms and rates, payment policies, medical policies, billing guidelines, and applicable regulatory requirements.
• Contributes new ideas for improving existing audit processes and audit queries. Works cohesively with the audit team.
• Conduct daily internal compliance audits and monitoring related to processed claims, analyze results and provide recommendations to address and resolve aberrancies.
• Must work collectively with various departments to detect, track and report claims payment compliance issues

Requirements

• High school diploma or equivalent.
• In depth knowledge of claims payment process and CPT, ICD-10, HCPCS and modifier coding requirements.
• Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial, Self-Funded Insurance), including ICD-10, CM codes, HCPCS codes, CPT codes, DRGs, physician billing, etc.
• 3+ years of healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting and/or claims auditing.
• Knowledge of Microsoft Office programs (Excel, Word, Outlook).
• Strong analytical skills.
• Self-motivated, hardworking individual with a high attention to detail.
• Ability to multi-task and produce deliverables within established time frames.
• Must be able to work independently.
• Ability to communicate effectively.

Nice-to-haves

• Associate's/Bachelor's Degree preferred.
• Understanding of all lines of business a plus (Medicaid, Medicare, Commercial, Self-Funded).
• 3+ years of claim payment experience.
• Experience in navigating health care regulations such as those issued by Medicare, Medicaid and the Affordable Care Act.
• Experience in healthcare auditing, reviewing and validating the accuracy of claims data and accuracy of claims payment preferred.
• Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data.
• Recovery audit experience a plus.
• Working knowledge of hospital and physician charging practices, payer reimbursement methodology, medical necessity criteria and applicable industry based standards.
• CPC, CMC, RMC, RHIT, RHIA, or other coding/clinical certifications, credentials, or expertise preferred.