Claims Quality Assurance Auditor in Dallas, Texas at TEXASCONNECT INC

Maintains positive working relationships with our internal and external customers, health plan’s, providers and/or members by seeking a partnership approach that will meet the company goals and vision. The CQA auditor will coordinate Health Plan’s audits activities with preparation and provide preliminary results on non-compliant issues to CQA manager. Oversees, audit findings and provide education to claims staff and other internal customers. Assists with developing an audit control checklist for prevention of claims timeliness, payment accuracy, systematic or statistical errors in managed care claims system. Develop a root cause analysis report for common trends to provide feedback to the claims staff/ team and/or internal customers. Oversees, in conjunction with the Managed Care Management Team, to ensure QA programs are aligned with claims operations and other areas that have direct impact with claims to prevent non-compliance. Adheres to internal department standard operating procedures and applies standard industry guidelines in accordance with regulatory agencies (state and federal). Researches, analyzes and resolves complex problems dealing with claims audits, including member denials, provider disputes, deficiencies that will potentially jeopardize the claims department. Has extensive knowledge of current and future claims processing, audits, compliance, adjustment, provider disputes, DOFRs and/or configuration, etc.

SPECIFIC SKILLS NEEDED

• Good skills in:
Computer systems (MS Excel and Word)
Written and verbal communication skills
Managed Care Knowledge and confidence exposure and expected
Knowledge of claims processing, CPT/RBRVS/ICD codes
Comprehension as it relations to regulatory compliance and guidelines associated with the following: CMS, DMHC, DOI, DHS, etc.
Analyzing data understanding the trends
• Expert skills in:
Claims auditing and understanding claims processing in a claims department
identifying compliance gaps in processes and systems by providing a risk based solution for prevention
Preparing, issuing, and tracking deficiencies noted during claims pre/post audit and inspection
Extensive knowledge on root cause analysis/trends
Ability to work independently with minimum supervision
Confidentiality and Honesty with compliance
Communicate with CQA manager
• Excellent skills in:
Organization
Meet deadlines and completion on assigned projects in a timely manner
Ability to take initiative in analyzing problems, developing a solution with a win-win approach
Great customer service skills with internal and external customers

EDUCATION/EXPERIENCE/TRAINING
Required:
• High School Diploma or GED
• 5 to 10 years claims processing experience
• Experience with implementation of Corrective Action Plan (CAP)
• Knowledge of regulatory requirements (CMS and DHS)
Preferred:
• Bachelor’s Degree