Senior Quality Assurance Specialist

Viva Health•Birmingham, AL

10d

About The Position

The Senior Quality Assurance (QA) Specialist is responsible for the validation of various processes to ensure accuracy, thereby providing superior service to our members and providers. This role is responsible for auditing and reporting analysis of Claims and Entry Staff, Commercial Customer Service, and Medicare Member Services Phone Queue Calls, System Configuration, and Provider/Fee Configuration. This position also assists with functions such as reconciliation reports, focus audits, check run reports, IS reports, secondary review of high dollar checks, and training team members.

Requirements

High School diploma or GED
3 years’ experience with all components of claims processing of Medicare enrollment and/or customer service
2 years’ QA experience
Some experience working with VIVA lines of business
Some PowerSTEPP experience
Knowledge of ICD10, CPT, HCPCS, HCFA, Uniform Billing codes, Coordination of Benefits (COB), VIVA HEALTH’S lines of business, and proficient in medical terminology
Strong Intermediate Excel knowledge
Demonstrate excellent customer service skills through strong written and verbal communication skills
Ability to prioritize and multitask while maintaining organization and attention to detail
Ability to be team focused working in a team environment, remaining flexible to ideas, routines, and schedules, recognizing responsibilities and actively participating with others to accomplish assignments and achieve desired goals

Nice To Haves

Coding experience

Responsibilities

Perform audits of other QA Specialists' work to ensure accuracy based on plan coverage, documented policies and procedures, company compliance, and all regulatory guidelines.
Be able to back up other QA Specialist positions as needed.
Maintain knowledge of all claims processes and ensure claims have adjudicated accurately prior to check-run update, identify root cause of incorrect processing.
Provide information of identified issues to staff to ensure correct processing.
Identify and report configuration issues and communicate with internal departments to resolve problems that affect claim payment.
Investigate claim submissions for coding inaccuracies, review high dollar remittances for payment and system configuration accuracy.
Provide training and education to team members on all lines of business as needed.
Produce and distribute QA Summary reports detailing individual and departmental errors, claims production, as well as other findings while maintaining confidentially with regard to individual error results.
Conduct phone audits of randomly selected and/or focused Member Services or Commercial Customer Service inbound phone calls including review of documentation and information in various systems.
Produce scorecard for each call audited.
Must be available to work within the core hours of operation, 6am to 6pm Monday through Friday and overtime as required.