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1199SEIU Benefit and Pension Funds · 1 month ago

Manager, Quality Assurance, Training and Recovery

New York, NY

Full-time

Onsite

Mid, Senior Level

5+ years exp

1199SEIU Benefit and Pension Funds is seeking a Manager for their Quality Assurance, Training and Recovery Unit. The role involves overseeing quality assurance processes, managing training for staff, and ensuring compliance with medical claims requirements while promoting financial efficiencies within the Fund.

Non ProfitRetirement

Responsibilities

Overseeing and managing the Quality Assurance, QNXT Medical, and Hospital Claim Training and Recovery Unit

Develop and maintain processes for objectively auditing and measuring the performance of individuals, systems, and departments. Ensure compliance with Medical and Hospital Claims Processor requirements and provide feedback to the relevant managers and supervisors. Identify incorrect payments and refer overpayments to recovery staff for recoupment. Educate QA staff to recognize potential fraudulent claim activity

Manage staff that conduct training classes for new hires and refresher training to improve the functions of the Medical, Hospital, Provider Relations, Care Management, Utilization, and Staff Claims Departments

Oversee staff who contact providers to recoup overpayments from physicians and hospitals that were previously identified by the Quality Assurance staff. Analyze unsolicited refunds to determine the cause and refer to department management for corrective action

Promote financial efficiencies and effectiveness within the Fund. Detect and prevent fraud and abuse by providers and members

Ensure that the Claims Staff have a thorough knowledge of both claims processes and are proficient in performing their essential duties and acquire the skills to achieve the department's goals and objectives

To ensure integration of the Fund policies, contracts, and procedures, and that system configuration is being maintained

Oversee testing related to QNXT upgrades, system enhancements, and external vendor processes

Perform additional duties and projects as assigned by management

Qualification

Hospital claims processingQuality assuranceAuditing experienceMicrosoft ExcelCPTICD-10HCPCS knowledgeLeadership skillsAnalytical skillsCommunication skillsOrganizational skillsTime management

Required

Bachelor's Degree or equivalent years of work experience required

Minimum of five (5) years hospital claims processing, quality assurance, auditing experience required; to include a minimum of two (2) years supervisor experience required

Intermediate level in Microsoft Excel required

Strong knowledge of CPT, ICD-10, HCPCS, UB-04 and hospital reimbursement methodologies; good understanding of hospital contracts

Knowledge of eligibility, medical terminology, third-party reimbursement and COB

Strong leadership skills required; able to make independent decisions concerning management, planning, scheduling, and assignment of work; excellent time management and data reporting skills

Strong analytical, critical thinking, interpersonal and communication skills (written and oral)

Excellent organizational skills; able to multi-task, prioritize and follow up and ability to work well under pressure in a fast pace environment

Preferred

Microsoft Word preferred

Benefits

1199SEIU National Benefit Fund

Company

1199SEIU Benefit and Pension Funds

The 1199SEIU Funds are among the strongest and largest labor-management funds in the nation, providing a range of comprehensive benefits to 400,000 working and retired healthcare industry workers — members of 1199SEIU United Healthcare Workers East — and their families.

Founded in 1945

New York, New York, USA

1001-5000 employees