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Driscoll Children's Hospital · 1 month ago

Claims Quality Analyst

Corpus Christi, TX

Full-time

Onsite

Mid Level

3+ years exp

Driscoll Children's Hospital is dedicated to compassion and innovation in healthcare, and they are seeking a Claims Quality Analyst. This role is responsible for ensuring the integrity of medical claims processing through auditing, trend analysis, and collaboration with internal partners to improve quality and training initiatives.

Child CareChildrenHealth CareMedical

Growth Opportunities

Responsibilities

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