Quality Control Reviewer III

 

 

Responsibilities

• Conduct audits and provide training assistance to staff in the Medical Claims Department
• Examine and finalize complex surgical, medical, vision, hearing aid and Medicare Part B claims; resolve pending, and re-pricing edit 671 for non-vendor claims, call tracking records, appeals, and explanation of benefits (EOB’s)
• Review and audit work production; research and appropriately apply credit refunds, research and apply void and reissues, and distribute work to staff
• Address and resolve complex questions and issues; communicate with other internal departments, , members and providers via Document Manuel System (DMS), telephone and form letters regarding claims information
• Provide assistance to staff with routine DMS/QNXT claim problems and answer questions regarding policies and procedures
• Log and update Medicare Secondary Payer (MSP) and other claim information on Excel spreadsheet; review correspondence, evaluate cases, prepare claims for processing, audit and assist preparing rebuttals
• Review and sign off on form letters completed by clerical department staff
• Complete medical consultant retrospective utilization review forms
• Research eligibility issues in Vitech (V3)
• Perform other duties and assignments as directed by management

 

Qualifications

• High School Diploma or GED required; some college or degree preferred
• Minimum of two (2) years experience processing, reconciling, adjusting, or resolving pended medical claims in the QNXT claims payment system required
• Working knowledge of Microsoft Word, Excel and Outlook preferred
• Excellent oral and written communication skills
• Ability to prioritize work quickly and accurately
• Demonstrated organizational skills with ability to multi-task and follow through on assignments