Claims Quality Assurance Analyst
Description
Title: Claims Quality Assurance Analyst
Department: Operations - Claims
About the Role:
Department: Operations - Claims
About the Role:
Quality Assurance Analyst is responsible for performing routine and complex audit of claims payment for pre- and post- check run. The QA analyst will summarize findings and provide recommendations to the reporting Supervisor and Manager. 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.
What You’ll Do:
- Conduct comprehensive reviews of professional pre-pay and post-pay claims including supporting documentation and other relevant information, to verify accuracy, completeness, and compliance with company policies and procedures and industry standards.
- Analyze claims processes and systems to identify gaps, inefficiencies, and potential risks, and provide recommendations for improvement.
- Utilize proper error codes and root cause codes with detailed explanation for precise identification of issues or discrepancies found during claims auditing for all claim types.
- Comply with regulatory requirements and guidelines that include but not limited to timely filing submissions, coordination of benefits, current payment methodology by line of business, Health Plan Matrices and DOFR (Division Of Financial Responsibility) and AB1455 rules.
- Identify incorrect billing and coding and apply NCCI edits if applicable.
- Request the reprocessing of claims or initiate a request for recoupment.
- Follow specific client business requirements for claims adjudication.
- Understand the types of providers 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-10, CPT, HCPC codes, general billing procedures for health care providers and institutions, as well as Medicare and Medi-Cal reimbursement guidelines
- Adhere to corporate standards for performance metrics, data integrity, and reporting format to ensure high quality, meaningful output, and the strictest confidentiality at all times.
- Perform other duties as necessary or assigned by NMM’s management team.
- Know the distinction between Shared Risk and Full Risk claims.
- Maintain required levels of production and quality standards as established by management.
Qualifications:
To perform this job successfully, this individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Bachelor's degree (B. A.) from four-year college or university
- EZ-CAP knowledge; or equivalent combination of education and experience
- Knowledge of MS Word, Excel and basic medical terminology is required
- Typing speed 50+ WPM and knowledge of 10 key desired
- Ability to multi-task and meet deadlines
- Strong organization skills; ability to multitask and properly manage time
- Position may require unscheduled overtime, week-end work
- Ability to understand work with proprietary software applications
- Organizational ability and ability to exercise good judgment
- Work independently as part of a team
- At least 5 years complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system
Who We Are:
Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient.
Our Values:
Our platform currently empowers over 10,000 physicians to provide care for over 1 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.
Our Values:
- Put Patients First
- Empower Entrepreneurial Provider and Care Teams
- Be Innovative
- Operate With Integrity & Excellence
- Work As One Team
Environmental Job Requirements and Working Conditions:
- This position is remotely based in the U.S. Employees are expected to operate during the corporate office hours in PST.
- The annual total compensation target pay range for this role is: $70,000 – 76,000. This salary range represents our national target range for this role.
Additional Information:
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at [email protected] to request accommodation.
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.