As a Claims Training and Quality Analyst, you will oversee and conduct various testing activities related to contract validation, benefit engine functionality, fee schedule accuracy, and other IT-driven initiatives within the claims processing environment. Additionally, you will perform claims auditing to ensure compliance with regulatory requirements and internal policies. A crucial aspect of your role will be to provide training and development to Claim Examiners and new team members, ensuring they are equipped with the necessary skills and knowledge to perform their roles effectively. You will play a vital role in training and developing staff involved in medical claims processing. You will design, deliver, and facilitate training programs to ensure employees understand and adhere to healthcare regulations, company policies, and best practices in claims adjudication. Your expertise will help maintain high standards of accuracy, efficiency, and customer satisfaction within the claims processing department.
You will utilize your expertise in medical coding, billing practices, and insurance policies to review and adjudicate claims efficiently while maintaining a high level of accuracy. This role requires strong analytical skills, attention to detail, and the ability to collaborate effectively with internal and external stakeholders.
Essential Duties and Responsibilities:
Conduct thorough contract testing to validate parameters and ensure compliance with contractual agreements.
Perform benefit engine testing to verify the accuracy and functionality of claims processing systems in alignment with plan specifications.
Test fee schedules to ensure accuracy and compliance with regulatory guidelines and provider contracts.
Collaborate with IT teams to participate in user acceptance testing (UAT) and regression testing for system upgrades and implementations.
Conduct claims audits to review processed claims for accuracy, completeness, and compliance with regulatory and organizational standards.
Identify trends, patterns, and potential issues through auditing processes, and provide recommendations for process improvements.
Analyze testing results and audit findings to identify discrepancies, trends, or areas for improvement in claims processing.
Investigate root causes of errors or issues identified during testing or auditing, and collaborate with IT and business teams to implement corrective actions.
Document testing procedures, audit findings, and resolutions to maintain comprehensive records and support continuous improvement efforts.
Ensure compliance with healthcare regulations (e.g., HIPAA, CMS guidelines) and internal policies during testing, validation, and auditing processes.
Implement quality assurance measures to uphold standards of accuracy, efficiency, and regulatory compliance in claims processing activities.
Provide training and guidance to claim examiners or new team members on testing methodologies, claims auditing processes, and best practices.
Develop training materials and resources to enhance the knowledge and skills of team members in claims processing, compliance, and quality assurance.
Conduct regular training sessions to ensure team members are up-to-date with industry trends, regulatory changes, and organizational policies.
Maintain detailed documentation of testing procedures, audit methodologies, findings, and recommendations for future reference and audit purposes.
Communicate effectively with cross-functional teams to convey testing and auditing findings, collaborate on solutions, and drive operational enhancements.
Collaborate with subject matter experts (SMEs), department managers, and stakeholders to identify training needs and objectives.
Facilitate training sessions through various mediums (e.g., classroom training, workshops) to educate employees on claims processing procedures, policies, and regulatory requirements.
Collaborate with department managers, to address training needs and align training initiatives with organizational goals.
Provide support and guidance to claims processing staff on complex claims cases or procedural inquiries.
Adjudicate claims based on established policies, guidelines, and fee schedules, making determinations on claim eligibility, coverage, and reimbursement.
Investigate and resolve discrepancies, errors, and discrepancies in claim submissions, collaborating with Claim Analysts as needed.
Maintain detailed records of claim processing activities, including correspondence, payment authorizations, audit trails and Claim notes.
Provide courteous and professional assistance to internal customers, and other stakeholders regarding claim inquiries, appeals, and disputes.
Stay updated on changes in healthcare regulations, coding guidelines, and industry best practices through.
Processes claim corrections and COB updates via interdepartmental customer relationship management process.
Complete side by side and peer training as necessary for educational opportunities.
Assists with projects and clerical support as needed.
This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.
Skills and Abilities
Proficiency in medical terminology, ICD-10, CPT, and HCPCS coding.
Strong analytical skills with the ability to interpret complex medical documentation and insurance policies.
Strong understanding of healthcare operations, claims processing workflows, and regulatory requirements.
Proficiency in testing methodologies (e.g., UAT, regression testing), claims auditing principles, and quality assurance practices.
Excellent analytical skills with the ability to interpret complex data, identify patterns, and make data-driven decisions.
Excellent communication and interpersonal skills with the ability to collaborate effectively with internal and external stakeholders.
Detail-oriented with a focus on accuracy and quality.
Proficiency in computer applications, including MS Office and claims processing software.
Ability to perform arithmetic calculations.
Ability to work independently.
Ability to meet deadlines.
Ability to maintain a good rapport and cooperative working relationship with the team.
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
Work Schedule:
As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week. *****The company reserves the right to change the work schedules based on the company needs.
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move up to 15 pounds.
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.
We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.
Qualifications
Certified Professional Coder (CPC) certification preferred. (Preferred)
Minimum of [4+] years of experience in medical Professional or Institutional Claims processing, preferably in a healthcare or insurance setting.