Job details
Job type full-time
Full job description
The claims quality inspector supports the department of operational improvement by effectively and accurately reviewing claims processed against established corporate guidelines and protocols specific to claim adjudication, both via manual and auto-adjudicationIdeal candidates will maintain a broad knowledge of corporate claims processing rules for use in conducting all reviewing functionsHe/she will also serve as support to the manager of operational quality assurance on an ongoing basis.
Key functions/responsibilities:
Conduct accurate and timely quality reviews of claim adjudication activities including appropriate adjudication decisions, accuracy of claim payment and compliance with adjudication policies and procedures
Document all findings in qc tracking system and provide clear communication and documentation for any error determinations
Consistently meet quality, productivity and timeliness standards set by management
Collaborate with other team members to meet team goals, update and maintain reference materials and qa resource documents to ensure consistent findings and determinations
Support internal department audits by demonstrating process workflow and providing system documentation and samples as requested
Provide immediate feedback to management as urgent issues or incorrect processing trends are identified
Provide support in the production and analysis of claims quality reports
Assist in the rebuttal process by providing supporting documentation and references tools sited in the determination
Effectively manage time and inventory within departmental guidelines
May be assigned to work on special projects and business initiatives by management
Qualifications:
Education:
High school diploma or ged required
Bachelor’s degree and/or medical billing/coding certification preferred
Experience:
At least 2 years of experience in a claims qc/inspector role within the managed care industry
At least 5 years of experience processing medical claims
Prior experience within the medicare, medicaid, or other regulated managed care payer environment preferred
Competencies, skills, and attributes:
Demonstrated competency with ms office and ms windows
Excellent analytical, oral, verbal, and written communication skills
Excellent organizational skills; must be very detail oriented
Must be able to multi-task, prioritize projects and work well with deadlines
Must be flexible and willing to perform all necessary and appropriate duties to ensure the attainment of departmental and organizational goals
Reliable transportation, auto insurance, and a valid driver’s license required
Ability to maintain a high level of confidentiality
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.
Required skills
Required experience
