Ops Quality Auditing Analyst

Amerihealth Caritas•Tinicum Township, PA

6d•Hybrid

About The Position

The primary purpose of the Operations Quality Auditing Analyst is to provide high-level technical expertise and analysis to the functional areas supported by the Quality Auditing department. They will work closely with configuration, PDM, and Plans to identify the root cause and drive to resolution. Work Arrangement: Hybrid= Associate must be in the office at least three (3) days per week, including core days of Tuesdays and Wednesdays

Requirements

Bachelor’s Degree or equivalent work experience
Minimum of 3 years of extensive claims experience
Strong understanding of facets applications
Critical thinking skills
Technically proficient
Proficient in MS Excel and Word

Nice To Haves

Be proficient in claim payment methodology for all plans
Have experience in researching State and CMS guidelines – including APR DRG and OPPS methodology
Proficient in Contract Manager and all contract/PAT forms

Responsibilities

Function as a key subject matter expert for all claim research and analysis
Be proficient in claim payment methodology for all plans
Have experience in researching State and CMS guidelines – including APR DRG and OPPS methodology
Maintain a current working knowledge of processing rules, contractual guidelines, Plan policy, and operational procedures to effectively provide technical expertise
Support the new business claim validation efforts by reviewing claim setup and identifying issues for quick remediation
Proficient in Contract Manager and all contract/PAT forms
Assist in analysis on pre-adjudication, target audits, and encounter reviews as required
Ability to research claim-related encounter errors and ascertain the root cause
Ability to communicate and represent the Quality Auditing team to the Enterprise, health plans, and outside auditors
Utilize various technology applications related to claim processing, provider data management, enrollment, etc. (Excel/Access/Word)
Identify audit trends and provide recommendations
Train the new QA staff on the pricing methodology for all plans.