Johns Creek (USA)
Posted 60 days ago
The Quality Assurance Auditor is responsible for reviewing, examining and investigating medical and dental claims paid, pended and denied to ensure that the appropriate plan/policy provisions, limitations and exclusions were administered and are in compliance with state and federal statutes and all internal processes and procedures.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Provides feedback to enhance quality service through identifying process deviations and training needs.
- Responsible for auditing all claims exceeding the processors draft limit and performing random audits on each processor as required.
- Completes specialized audits for Pre Authorizations, Appeals, Financial Recovery, and Denial letters.
- Responsible for auditing all claims processed by a trainee, providing trend reports and recommendations for gradual draft limit increases based on the audit results.
- Identifies audit trends and provides constructive feedback to the trainer for additional needs and the claims supervisor for coaching needs.
- Responsible for handling all Center of Excellence Transplant/Cancer claims.
- Performs similar job-related duties as assigned.
To perform this job successfully, the Quality Assurance Auditor 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.
- Demonstrate strong analytical skills.
- Extremely detailed oriented.
- Excellent organizational skills.
- Effective verbal and written communication skills.
- Working knowledge of claims and plan/policies.
- PC skills.
- Working knowledge of medical terminology.
- Working knowledge of auditing techniques
- Working knowledge of state statues, ERISA and the principles of the National Association of Insurance Commissioners (NAIC) model ‘Unfair claims Practice’ bill.
- Ability to interpret contracts, analyze claims information.
- Ability to work independently in a fasted paced environment.
- Ability to be flexible to changes in standard auditing duties.
- Working knowledge of ESRD, Medicare and COB.
EDUCATION and/or EXPERIENCE
Associate’s degree (A.A) or equivalent from two-year college or technical school; or 5-7 years related experience in short term medical, group and individual insurance; or an equivalent combination of education and experience with no less than 3 years of medical claims processing with 1 year at a senior level.