Claims QA Specialist
New Century Health is leading transformative change in specialty care management. By combining medical management expertise with a deep understanding of healthcare informatics, physician management and healthcare technology systems development, we generate insights that drive leading edge and effective innovation. What does this mean to you? It means that when you join us, you will be a key contributor to one the fastest growing healthcare services in the National Oncology and Cardiology care management space today. With your knowledge, skills and abilities, you will impact the delivery of care and directly contribute to our ability to positively impact and meet the critical unmet needs of patients suffering from all types of cancer.
We support our employees with an outstanding benefit package that features programs like employee paid medical benefits, 100% match on your 401k contribution up to 4% of your base salary, generous tuition reimbursement, as well as above average paid time off. If you are interested in working with some of the most dedicated, passionate and smartest people on the planet, express your interest in speaking with us and we will respond immediately.
The Quality Assurance Specialist is responsible for ensuring compliance with applicable healthcare claims standards and regulations through process review, approval, audits and systematic maintenance of quality systems. The scope of activities include production and process controls, change management, validations, system testing, risk management, procedural review and creation, and process improvements.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Performs quality audits for provider set-up including but not limited to contract agreement.
- Conducts compliance audits of complex documentation and data.
- Reviews quality outputs for compliance to internal and external requirements.
- Reviews and assesses appropriateness of document changes in accordance with internal procedures.
- Contributes to reviewing adequacy of root cause, corrections, corrective actions, preventive actions and effectiveness.
- Identifies and leads continual improvement projects with cross functional team members.
- Develops and implements quality system processes.
- Performs testing (writes, executes and reports on test cases) of systems configuration changes to ensure proper claims adjudication including Medicare Fee schedules, benefits plans, provider agreements and contract arrangements, claims editing, authorization and general system maintenance requests.
- Reports or escalates issues to Sr. Claims Manager timely.
- Respects and maintains HIPAA confidential guidelines.
- Acts as an interdepartmental liaison between all New Century Health offices, departments and Providers.
- Acts with honor and integrity, serving as a role model for the company.
- Performs other duties as assigned.
EDUCATION and/or EXPERIENCE:
- Associate's degree in a related field or equivalent relevant work experience.
- Five (5) years related experience in a managed care or insurance environment.
- Five (5) years’ experience in processing claims.
- Knowledge of health plan claims processing, system configuration and testing.
- Comprehensive knowledge of medical terminology as well as CPT4, HCPCs and ICD-9 coding sets is required.
- Prior experience in testing, quality assurance and quality improvement practices.
OTHER SKILLS and ABILITIES:
- Extensive knowledge of claims management processes for multiple product lines/specialties.
- Must be an excellent problem solver and proactive solution seeker.
- Ability to work in a fast paced environment.
- Excellent attention to detail; sound judgment; initiative and flexibility.
- Strong interpersonal communication and relational skills.
- Excellent verbal/written communication skills; ability to interact within all levels of the organization.
- Ability to give clear communication to staff and to train in a logical manner.
- Must be able to foster a positive and productive work environment with ability to lead and motivate staff in collaboration with Management.