Technical Quality Control Reviewer III

Responsibilities:

• Conduct audits of medical and hospital claims, providing quality assurance and technical support of claims processing, and analyze contracts versus system configuration discrepancies (QNXT)
• Evaluate and analyze compliance with standards and outcomes for all claim activities including clerical and data entry functions for Medical and Hospital departments
• Monitor performance for systems related to all claim processes, particularly electronic, imaging, verification, and pay-to-assignments
• Review performance of automated software such as Claimcheck/CCI/ edits
• Track compliance with all policies and procedures of the Medical, Hospital, Eligibility, and Care Management departments
• Analyze overpayments on unsolicited refunds to determine trends, identify system issues and payer errors with a view to developing recommendations for mitigation, review, track and communicate hospital, medical and dental claims processing trends as the results of audits
• Identify trends, report results and make recommendations regarding training, management controls, procedures or system updates; perform special reviews as needed
• Request refunds for erroneous payments from members and providers; add memo alerts in claims history respond to inquiries and Call Tracking issues
• Update overpayments and refunds received on Recovery Application and Memo Alerts in claim history; and telephone calls or send follow letter to obtain refunds
• Perform other duties as assigned by management
   

Qualifications:

• High School Diploma or GED required, some College or Degree preferred
• Minimum two (2) years experience as a Quality Control Reviewer in claims processing to include reconciling, adjusting and resolving medical or hospital claims
• Extensive knowledge of V3 eligibility, QNXT medical, hospital, dental, and claims processing systems
• Basic knowledge of Microsoft Word and Excel; strong computer skills
• Familiarity with handling suspended claims and making adjustments
• Excellent oral and written communication skills
• Strong organizational and analytical skills
• Ability to work independently and be a team player