Astrana Health Careers

Description

Job Title: Quality Assurance Lead

Department: Operations - Claims SoCal

About the Role:

Under the general direction of the Claims Compliance Manager, the Director of Claims Operations and/or Director of Operations, this position will be responsible for performing routine and complex audit of claims payment for pre- and post- check run. The Quality Assurance Lead will summarize findings and provide recommendations to the reporting Supervisor/ Manager as well as the Director of Claims Operations and Director of Operations. The position is expected to clearly understand the products & healthcare benefit services offered to the capitated members that we manage, including the division of financial responsibility, as well as the associated limits and regulatory rules and guidelines. Quality Assurance Lead will ensure that the claims are adjudicated in accordance to State, Federal, Health Plan, Network Medical Management guidelines.

What You'll Do:

• Lead and conduct pre-pay and post-pay audits to ensure accurate claims payments and denials for all level of examiners and to capture deficiencies in processed claims prior to check run.
• Advanced knowledge in, and knows how to use and apply Health Plan Benefit Matrices and DOFR (Division Of Financial Responsibility).
• Lead the correction of claim adjudication errors.
• Test and audit new releases of Medicare and Medi-Cal Fee Schedules, provider payment pricing methodologies based on contract agreements.
• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to health plan operations or as documented in company policies and procedure.
• Advanced understanding of AB1455 Claims Settlement Practice & dispute and resolution regulations.
• Be able to understand and interpret the types of provider contracting arrangements and/or benefits administration data elements that need to be configured in the appropriate applications to support the accurate & timely payment of claims.
• Maintain knowledge of all ICD-9, CPT, HCPC codes, general billing procedures for health care providers and institutions, as well as Medicare and Medi-Cal reimbursement guidelines.
• Knowledge and understanding of rate application for all outpatient and inpatient facility, ASC, APR-DRG, DRG, interim rate, 3M Core Grouping and CMAC rates of payment methods to appropriated line of business. (Medicare, Medi Connect, Commercial and Medi-Cal).
• Lead in the identification of any incorrect billing, coding, NCCI edits, duplicate payments, and incorrect payment adjudication.
• Test and audit claims payments for accuracy against contract information loaded into EZCAP and provide summary results to management
• Generate and utilize audit reports for identifying claim adjudication errors.
• Document each individual review process, justification and conclusion.
• Track and analyze claims adjudication errors.
• Advise and recommend solutions to drive improvement
• Identify trends and work with claims management to develop action plans and metrics to ensure consistency of processing across the operations area
• Makes recommendations for process improvement initiatives
• Ensure that the Quality Auditing program is working as intended and make adjustments where necessary
• Constant collaboration with the Claims Trainer to ensure that we are training based on identified error trends
• Assist with the auditing of our automation queries

 Qualifications: 

• Four years claims experience preferred to include adjustments and auditing
• Knowledge of MS Word, Excel, EZcap, Virtual AuthTech, Encoderpro and other basic medical terminology is required
• Accepts change as a normal part of doing business, maintains a positive attitude and exhibiting constructive work behaviors during periods of transition
• Meets work and attendance expectation; informs others in advance when commitments cannot be fulfilled
• Actively supports organizational goals and values; aligns actions around organizational goals; gives priority to organizational needs and concerns when making decisions
• Takes a reasoned logical approach in making judgments and decisions, carefully reviews available facts and information before reaching any conclusions
• Identifies and gathers relevant information, consults the right people and asks the right questions in a given situation
• Demonstrates disciplined thinking that is clear, unbiased, analytical and informed by evidence
• Effectively communicate with others.
• Minimum high school diploma or GED is required.
• Minimum of four (4) years of experience in healthcare claims processing, including either adjustments, provider dispute resolution and/or auditing
• HCPCS, CPT, ICD10 coding experience is required.
• Knowledge of Medicare, Medicaid, or commercial insurance is needed. Knowledge of various payment and pricing methodologies.
• The ability to deal with confidential information is essential.
• Excellent verbal and written communication skills, including the ability to effectively communicate with internal and external customers.
• Excellent computer proficiency in MS Office products including expertise in MS Excel (creating spreadsheets and using advanced formulas) and PowerPoint.
• Must be able to work under pressure and meet deadlines, while maintaining a positive attitude and providing exemplary customer service.
• Ability to work independently and to carry out assignments to completion within parameters of instructions given, prescribed routines, and standard accepted practices.
• Understands and is able to apply insurance laws and regulations.

You're great for this role if:

• Coding certification is preferred.
• Has EZCAP experience

• Put Patients First 
• Empower Entrepreneurial Provider and Care Teams 
• Operate with Integrity & Excellence 
• Be Innovative 
• Work As One Team