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MetroPlusHealth · 17 hours ago

Claims Quality Analyst

New York, NY

Full-time

Onsite

Mid Level

$55K/yr - $65K/yr

4+ years exp

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. The Claims Quality Analyst is responsible for reviewing claims to ensure payments are correctly made, analyzing data for payment validity, and suggesting process improvements while assisting in training and auditing processes.

Financial ServicesHealth CareHealth InsuranceInsuranceLife Insurance

Responsibilities

Audit daily processed claims through random selection based on set criteria

Document, track, and trend findings per organizational guidelines

Based upon trends, determine ongoing Claims Examiner training needs, and assist in the development of training curriculum

Conduct in-depth research of contract issues, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends. Recommend actions/resolutions

Work with other organizational departments to develop corrective action plans to improve accuracy of the claims adjudication processes and assure compliance with organizational requirements and applicable regulations

Assist in the development of Claims policies and procedures

Provide backup for other trainers within the department

Assist in training of new departmental staffs

Assist with the research and resolution of audit appeals

Asist with external/internal regulatory audits

Identify policies or common errors requiring retraining sessions

Participate in quality projects as required

Collect, analyze data, identify trends, write reports (i.e., the monthly and quarterly reports) and present findings to the appropriate claims service management personnel

Other duties as assigned by senior management

Qualification

Claims quality auditsClaims coding expertiseProvider contracting knowledgeCMS Medicare regulationsTraining developmentData analysisPC application proficiencyTrustOrganizational skillsCommunication skillsIntegrity

Required

Associate degree required; Bachelor's degree preferred

Minimum of 4 years of experience performing claims quality audits in a NYS-based managed care setting

Expertise in both professional and institutional claims coding, and coding rules required

Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and standard industry reimbursement methodologies required

Strong knowledge of CMS Medicare and NYS regulations required

Strong organizational, analytical, and oral/written communication skills required

Proficiency in PC application skills, e.g., excel, word, PowerPoint, etc

Must be able to follow direction and perform independently according to departmental

Integrity and Trust

Must have excellent interpersonal, verbal, and written communication skills