Claims Quality Auditor

PRIMARY PURPOSE

Reviews, analyzes, and adjudicates professional claims, claim appeals, corrected claims and refunds from UTSW for physician services performed on Parkland unfunded patients, to ensure accurate records and disposition of claims in accordance with contractual business rules. Performs claims data analysis and presents results and recommendations to the department leadership.

MINIMUM SPECIFICATIONS

Education

• Bachelor's degree in health or finance-related field is required.

Experience

• Must have five years of experience in accounting, business office, or medical insurance claims environment, in a large volume environment.
• Must have experience with Medicare billing/reimbursement rules and regulations.
• Must have experience in large data management.
• Must have experience with Texas Medicaid program eligibility guidelines.
• Must have knowledge of ICD10, CPT physician coding/billing operations, and medical terminology.
• Prefer experience with EPIC software.
• Prefer experience in SQL (Crystal Reports) report writing.

Equivalent Education and/or Experience

• May have an equivalent experience in lieu of specific education.

Certification/Registration/Licensure

• None.

Skills or Special Abilities

• Must understand managed care and government payers' reimbursement principles, billing and claim adjudication processes.

• Must be able to observe emerging trends and track them using analytics and critical thinking methods.

• Must have a demonstrated ability to develop clean, insightful, and easily digestible potential financial impact and claims data.

• Must be able to conduct financial reconciliation projects using logic, revenue cycle and professional billing/claim adjudication knowledge with criteria and data elements provided.

• Must be able to demonstrate expertise with SQL reporting (example: Crystal Reports). Must be able to prepare detailed and summary reports and charts.

• Must have expert level skills in Microsoft software, including Word, Excel, Access, PowerPoint, Outlook, and Visio.

• Skilled with the ability to receive strategic direction and execute with minimal supervision

• Must be detail oriented, organized, and possess strong analytical and mathematical skills to ensure accurate and timely processing of accounting records and resolve complex accounting issues.

• Must demonstrate ability to meet deadlines while balancing competing demands.

• Must demonstrate ability to identify and research data irregularities.

• Must be able to solve problems within the guidelines of established policies and procedures.

• Must be able to communicate effectively with internal and external customers. Must be customer service oriented.

• Must have experience with project management methodology.

Responsibilities

• Analyzes, documents, and adjudicates monthly claims data, appeals, corrected claims and refunds for professional clinical services for Parkland covered patients.

• Performs a detailed quality assurance of claims processed by the Third-Party Administrator (TPA). Generates patient eligibility and coverage reporting from EPIC and validates patient's unfunded status.

• Provides data management support and creates custom reports to illustrate claim adjudication trends and issues for administration. Implements recommended revisions to process or TPA system set up as needed, to streamline claim, appeals and refunds adjudication.

• Identifies trends in TPA errors that have resulted in appeal claims. Reports those trends to Manager of Department Systems and assists with corrective measures with the TPA or UT Southwestern Finance team.

• Collects and aggregates claims data, translates business questions from the leadership team and translates them into analytical solutions. Presents analysis results/recommendations to the leaders in a timely, consistent, and accurate manner.

• Provides revenue reporting and data extracts for an annual Divisional Guarantees reconciliation process.

• Collaborates with internal IT and external TPA vendor to ensure adherence to the UT Contract business rules of adjudication. Works to ensure annual updates and modifications to the business rules are implemented.

• Work with large data for ad hoc reporting and trend analysis for UT Contracts Team.

• Validates denial reasons and ensures coding is accurate and reflects the denial reasons. Coordinates with the Nurse Auditor for clinical consultations or account referrals when necessary.

• Provides guidance and support to all UT Contracts personnel toward resolution of claim-related issues with an emphasis on root-cause analysis and problem resolution.

Job Accountabilities

• Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.

• Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.

• Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.