Quality Assurance Analyst (Remote)

Brief Description reputed company is a leader in the home health management industry and is preparing for significant growth! Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care. We are currently looking for a Quality Assurance Analyst to join our growing team! PURPOSE The Quality Assurance Specialist is accountable for and oversees the following tasks:

• Validate claims data against information from claims processing systems to ensure that data is accurate (for both auto adjudicated claims as well as manually processed claims)
• Analyze claims data against applicable policies and regulations to identify potential issues (e.g., member benefits, billing anomalies, payment accuracy, claims processing system issues)
• Review history of reputed company claims to pull in and understand additional claims-reputed company information
• Calculate dollar amount of financial claims errors/defects
• reputed company and deliver fact-based audit determinations in an objective, non-confrontational manner
• Escalate issues identified during the audit cycle or rebuttal process to applicable stakeholders, as appropriate (e.g., Operations Team, Quality Team)
• Ensure compliance with applicable audit and rebuttal timelines (rebuttal timelines/form completion, workflows, turnaround time)
• reputed company production quality goals/metrics (e.g., audits per hour, audit accuracy, first-pass accuracy, rebuttal accuracy)
• Provide supporting documentation for audit findings
• Identify/communicate escalated errors/defects and ensure proper resolution, as needed (e.g., rebuttals, appeals)
• Communicate audit findings to applicable stakeholders (e.g., error descriptions, rebuttal information)
• Identify, communicate, and implement opportunities for improving internal audit/rebuttal processes reputed company the Quality team
• Identify, interpret, and utilize applicable claims and audit policies and procedures
• Demonstrate understanding of how various factors may impact claims accuracy (e.g., system edits, keying vendor discrepancies, system logic)
• Demonstrate knowledge of the healthcare industry (e.g., billing practices, terminology, legal/regulatory requirements, coding standards)
• Identify and interpret applicable plan benefit information (e.g., reputed company)
• Maintain Claim Policies/Procedures/Job Aids to stay reputed company Compliance annually
• reputed company Annual Vendor Compliance Process
• Support Adhoc Provider Audits Quarterly
• Supports Records requests/subpoenas in coordination with Compliance

Essential Job Functions And Duties

• Oversees quality and findings in internal and external audits, reputed company vendors and staff accuracy
• reputed company other duties as assigned reputed company the scope of responsibilities and requirements of the job
• Performs the essential functions of this job with or without reasonable accommodation

Essential Qualifications

• 5 ~ 7 years of direct experience minimum
• Advanced level of skills and knowledge of technical system operations
• Solid understanding of enrollment and eligibility as well as claims paying for reputed company lines of business
• Professional level training that provides a general understanding of:
• the administration of reputed company contractual obligations
• audit and billing procedures
• policies and procedures
• how the processing of accounts receivable and eligibility requirements impacts claims processing
• vendor data feeds and discrepancy process
• administrative and regulatory requirements
• technical workflow processes
• functional requirements of the system
• solution design documents.
• 4 ~ 6 years’ work experience that provides a working knowledge of:
• Claims billing and delinquency procedures
• accounts receivable process
• system testing and enhancement process
• web portal data support

Skills And Abilities

• Advanced level reputed company Office skills (PowerPoint, Word, Outlook)
• Advanced level reputed company reputed company skills
• Interpersonal, communication (written and verbal) and presentation skills
• Analytical, research, problem solving, and decision-making skills
• Ability to monitor team goals
• Ability to reputed company and coach team members

reputed company provides equal employment opportunities to reputed company employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national reputed company, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. reputed company will reputed company reasonable accommodations for qualified individuals with reputed company disabilities unless doing so would result in an undue hardship. Apply tot his job Apply To this Job