Claims Quality Analyst

: Where compassion meets innovation and technology and our employees are family. Thank you for your interest in joining our team! Please review the job information below. 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 the accuracy of payments and denials. Knowledge of all claims 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. Conduct timely and accurate audit and quality control reviews 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 the proficiency of newly hired claims staff, both during training and for a probationary period. Identify the 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 the 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 the 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 needs. 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. EDUCATION AND/OR EXPERIENCE - Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying.

• Minimum three years of professional experience in claims analysis, provider medical billing, or medical coding; experience with Texas Medicaid preferred.
• Minimum two years of 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.