Senior Quality Analyst (Claims)

Summary of Position

• Perform audits and/or provide oversight and guidance to Claim Auditors in completing comprehensive random audits of claims, membership and service inquiry adjustment transactions.

• Determine the root causes of error and recommend appropriate corrective actions to prevent re-occurrence of these errors.

• Support cross-functional Business Transformation initiatives with quantitative transactional analyses and sample audits.

• Support Business Transformation Leaders leading business improvement and integration projects with problem definition and resolution.

Principal Accountabilities

• Perform timely post-payment audits of all claim types to verify the accuracy of the claim payment and processing.

• Perform cycle time analysis and audits of EmblemHealth of root cause and corrective actions

• Perform comprehensive audits of service inquiry adjustment transactions to verify that inquiries from groups, providers and subscribers are resolved accurately and timely.

• Conduct special audits as directed by senior management, including subcontracted operational capabilities.

• Provide problem definition/analysis support to the Business Transformation Leaders and their associated process improvements projects.

• Review and evaluate management responses and corrective action plans related to audit findings; negotiate disputed findings and recommendations with area management.

• Analyze all audit results and identify the root causes of errors.

• Develop appropriate and cost-effective recommendations

• Work with Claims, PFO, PNM, Membership and IT to identify any required system logic modifications related to audit findings.

• Participate in the external audit process, provide instruction to the auditors, research and coordinate responses to specific audit issues or to questions as directed by departmental management.

• Perform comprehensive reviews of new product or system implementations, as requested by management.

• Verify that applicable system data files are updated and claims are accurately adjudicated in accordance with contractual benefit provisions in conjunction with the reviews.

• Regular attendance is an essential function of the job. Perform other duties as assigned or required.

Qualifications

Education, Training, Licenses, Certifications

• Bachelor's Degree required; Additional year of experience and/or specialized training may be used in lieu of educational requirement

Relevant Work Experience, Knowledge, Skills, and Abilities

• 3 - 5 years relevant work experience, preferably in auditing and improving operational processes required

• Prior extensive experience in quality and/or root cause analysis required

• Prior knowledge in insurance coding and/or claims experience required

• Knowledge of EmblemHealth's processes and Facets system preferred

• Strong problem solving and verbal and written communication skills required

• Advanced PC literacy with emphasis on Cognos, MS Excel and MS Access required

Additional Information

• Requisition ID: 1000003293
• Hiring Range: $56,160-$99,360