Claims Quality Control Auditor

Company: Neighborhood Health Plan of Rhode Island
Location: Smithfield
Posted on: May 21, 2023

Job Description:

The Claims Quality Control Auditor ensures organizational claim processing complies with contractual and regulatory requirements. The position performs audit functions for internal and external clients, provides training standards based on findings; creates statistical auditing reports for management; identifies trends and potential issues with claims processing, and recommends process improvements to maximize accuracy.Duties and ResponsibilitiesResponsibilities include, but are not limited to the following:Review Neighborhoods claim process functions, including auto-generated adjudicated claims, based on provider and health plan contractual agreements and claims processing guidelines.Adheres to internal processes/procedures that ensure claim auditing functions comply with company policies and procedure standards.Advises and assists external departments with claims research and processing issues.Prepares statistical audit reports on audit findings, scores and corrective actions.Document and communicate claim issues identied during QC process and notify appropriate staff.Identifies root cause analysis for claim errors, and collaborate with internal and external departments to develop and implement solutions for resolution.Monitor claim error corrections reported in the audits.Report claims with suspected fraud, waste and abuse to management, and submits referrals to Special Investigation Unit.Meets with training department and claims management to recommend training related to QC reporting.Other duties as assigned.Corporate Compliance Responsibility - Responsible for complying with Neighborhoods Corporate Compliance, Standards of Business Conduct, applicable contracts, laws, rules/regulations, policies and procedures as it applies to individual job duties, the department, and Company. This position exercises due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agentsQualificationsRequired:High School Diploma or GED equivalentMinimum 3-5 years directly related experience in medical billing or claim examiningMinimum 1 year experience working on Medicare / Medicaid / or Commercial/Managed Care claimsDemonstrated knowledge of healthcare regulations and guidelines including Center of Medicare and Medicaid Services (CMS), Correct Coding Initiative, CPTs, ICD10sDemonstrated aptitude to perform mathematical functions (i.e., calculations/discounts/interest commission/percentages, etc.)Proficiency in spreadsheets and Microsoft OfficeAbility to read understand and apply contract termsExcellent communications and interpersonal skills including group presentationsAbility to work both independently and in a team-based environmentPreferred:Certified Professional Coder (CPC) certificationKnowledge of COGNOS reporting environment.Data analytics experienceNeighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

Keywords: Neighborhood Health Plan of Rhode Island, Providence , Claims Quality Control Auditor, Accounting, Auditing , Smithfield, Rhode Island