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The Claims Quality & Support Specialist responsible for activities concerned with review and inspection to apply quality standards for operational claim processes and adjudication.
What you do
•Prepare concise documentation and audit reports, including recommendations to claims management for improvements with corrective action plans;
•Audit, assess, and monitor providers and payers, to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral healthcare, laboratory, etc. medical records, and independently codes, and abstracts.
•Analyze inpatient and outpatient medical records using most current International Classification of Diseases (ICD-9/ICD-10),Current Procedural Terminology (CPT), Health Care Common Procedure Coding System (HCPCS), Universal Billing (UB) and other codes, regulatory and contractual requirements, and generally accepted coding practices.
•Verify and validate claims documents received through multiple channels to rule out possibility of documentation / coding errors or other inconsistencies that may occur in case of suspected fraud and abuse cases.
•Special focus and priority will be given to regulatory audit requirements, reports and findings.
•A summary of findings will be issued on monthly basis through a report, including recommendations on changes to be made, aligned with the Claims Quality Manager
•Any other task required by the manager, within the scope of Audit and Claims Support
What you bring
•Bachelor’s Degree (Medical Degree or Nursing)
•Minimum 5 years’ experience from Providers/TPA’s in processing/adjusting claims (e.g. ICD-9/10, CPT, HCPC) or Minimum 3 years’ experience auditing experience
•Demonstrated understanding of medical claims processes and procedures, and ability to recognize and interpret variances
•Legally permitted to work in the country of operations.
•Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills
•Problem solving skills
•Analytical skills
•Decision making skills
•Ability to work in a team environment
•Knowledge of applicable quality standards
•Excellent time management skills
•Follow-up technicalities
•Effective verbal, listening and writing communication skills
•Stress management skills
What we offer
Our employees play an integral part in our success as a business. We appreciate that each of our employees are unique and have unique needs, ambitions and we enjoy being a part of their journey.
We are there to empower and encourage you with your personal and professional development ensuring that you take control by offering a large variety of courses and targeted development programs. All that in a global environment where international mobility and career progression are encouraged. Caring for your health and wellbeing is key priority for us. This is why we build Work Well programs to providing you with peace of mind and give the flexibility in planning and arranging for a better work-life balance.
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67537 | Customer Services & Claims | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent
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