Claims Quality Analyst

GENERAL PURPOSE OF JOB

The Claims Quality Analyst will be responsible for ensuring the integrity of medical claims processing.   The position is responsible for auditing adjudicated claims, as well as trend analysis of overpaid claims, for accuracy of payments and denials.  Knowledge of all claim procedures, claim types and varying pricing methodologies is essential.  This position provides continuous feedback to internal staff, as well as collaboration with internal business partners in resolution of cross-departmental issues.  This position additionally assists in the development of appropriate training and procedural solutions related to quality improvement initiatives.

ESSENTIAL DUTIES AND RESPONSIBILITIES – Individuals in this position may perform any or all of the below listed duties. These should be interpreted as examples of the work and are not necessarily all-inclusive.

• Conduct timely and accurate audit and quality control review of both manual and auto-adjudicated claims (focused and random audits), calculating financial, procedural, and overall accuracy of the claims adjudication process.

• Perform an increased frequency of quality audits to determine proficiency of newly hired claims staff, both during training and for a probationary period.

• Identify root cause of claims errors through such methods as adjudication audit, overpayment analysis, and adjustment reasons; communicate findings to leadership and provide guidance in quality improvement initiatives related to errors.

• Identify training and process improvement needs based on claim adjustment, overpayment, adjudication error, and research results; collaborate with management and training partners in development of solutions.

• Provide effective communication regarding trends as well as recommendations to support adherence to claims quality best practice outcomes.

• Provide support, mentoring and assistance to claims staff in achievement of departmental quality expectations.

• Develop and participate in QA calibration meetings with departmental leadership to ensure consistency of quality audit activities, expectations, and improvements.

• Document, track and communicate monthly individual and team quality results, providing more frequent updates as required by business need.

• Identify individual or team quality deficiencies and create and implement action plans for remediation, with regular monitoring and communication of progress.

• Openly participate in team meetings, providing ideas and suggestions to ensure departmental efficiency and quality, and to promote teamwork.

• Maintain required compliance with privacy and confidentiality standards.

• Maintain or exceed all established standards for performance, quality and timeliness.

• Demonstrate business practices and personal actions that are ethical and adhere to all Health System and Health Plan policies and procedures.

• Assist with other related work responsibilities as requested.

EDUCATION AND/OR EXPERIENCE:

• Minimum three years professional experience in claims analysis, provider medical billing, or medical coding; experience with Texas Medicaid preferred.
• Minimum two years professional experience with Claim analysis; experience with Texas Medicaid preferred
• Prefer experience in medical claims auditing.
• Minimum High school graduate or GED required.
• Six Sigma experience preferred.