Quality Assurance Spec
About The Position
The Quality Assurance Specialist audits claims coding, customer service calls or electronic files for accuracy, benefit payment, contract interpretation, and compliance with policies and procedures. SKILLS Duties and Responsibilities: Updates and completes daily, monthly, and annual reports. Prepares responses to correspondence and manages complex provider issues and calls. Answers questions from PDM staff and other departments regarding provider updates and issues. Makes recommendations to improve quality, workflow processes, policies, and procedures. Credentialing: Chairperson SAL Audit VP Files (CVO Initial & CVO Re-Creds) WAP Audit OGM Invalid License IH Initial & Re-Creds Cred Verification MS Review Audit Contract Audit Provider Verification: Provider Relations: Call Audits Service Issue Audit Case Audit Audit Errors Assists with department training. Contributes independently and collaboratively across departments and cross-functional projects. Analyzes audit reports and rebuttals to identify trends and recommend determination of outcome. Reviews and makes suggestions for changes/updates to training materials and existing desk-level procedures and policies.
Requirements
- Requires an associate's degree. Will consider additional experience in lieu of degree.
- Requires 4 years of related experience.
- Requires effective written and verbal communication skills to answer questions from staff and providers.
- Requires proficiency with MS Word and MS Excel.
- Must have thorough knowledge of Provider Data Management policy and procedures.
- Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
- A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
- Latency (ping) response time lower than 80 ms
- Hotspots, satellite and wireless internet service is NOT allowed for this role.
- A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Nice To Haves
- Experience as an Associate Quality Assurance Specialist within PDM.
Responsibilities
- Updates and completes daily, monthly, and annual reports.
- Prepares responses to correspondence and manages complex provider issues and calls.
- Answers questions from PDM staff and other departments regarding provider updates and issues.
- Makes recommendations to improve quality, workflow processes, policies, and procedures.
- Assists with department training.
- Contributes independently and collaboratively across departments and cross-functional projects.
- Analyzes audit reports and rebuttals to identify trends and recommend determination of outcome.
- Reviews and makes suggestions for changes/updates to training materials and existing desk-level procedures and policies.
Benefits
- Competitive pay/salary ranges
- Incentive plan
- Health/Vision/Dental benefits effective day one
- 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
- Robust employee well-being program
- Paid Time Off
- Personal Community Enrichment Time
- Company-provided Basic Life and AD&D
- Company-provided Short-Term & Long-Term Disability
- Tuition Assistance Program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
