Claims Specialist Quality Assurance I

Inland Empire Health Plan•, CA

8d•$26 - $33•Remote

About The Position

Under the direction of the Claims Quality Assurance (QA) Manager and Supervisor, the Claims Specialist Quality Assurance (CSQA) is responsible for ensuring the integrity of all data created and updated by the Claims Processing staff. The CSQA will utilize quality auditing tools, identify training needs, and define effective and efficient methods for accurate data entry and adjudication. The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

Two (2) years of experience in examining and processing institutional and professional claims
Medicare/Medi-Cal experience preferred
Experience in a managed care environment helpful
High school diploma or GED required
ICD-9/ ICD-10 and CPT coding and general practices of claims processing.
Familiarity of Webstrat, Optum and CMS pricing
Excellent communication and interpersonal skills, strong organizational skills
Microcomputer skills, proficiency in Windows applications preferred
Professional demeanor

Nice To Haves

Medicare/Medi-Cal experience
Experience in a managed care environment

Responsibilities

Review and assess data reports and audit Claim Processor output to confirm payment accuracy and completeness of data entry.
In-house expert for claims adjudication (Coordination of Benefits, pricing, contract interpretation, coding, and resolution of claims issues.)
Ensure that all identified errors are corrected in an expedient manner.
Be an active participant in the Claims Department’s initiatives and participate in the Claims Coaching process, MDI activities, etc.
Assist with the processing of claims when necessary to address claims backlogs. Process approved Stop Loss reimbursements.
Any other duties as required, to ensure the success of the organization.
Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.