The Quality Assurance Specialist is responsible for ensuring that provider appeals and disputes meet established standards set by the department and regulatory requirements. Performs quality reviews to ensure all provider appeals and disputes are processed accurately. Documents audit findings and identify areas of improvements and/or training opportunities. Prepares and submit performance reports and other required departmental reports to Management.

General Duties/Responsibilities (May include but are not limited to):

• Performs review of provider disputes, appeals and inquiries to ensure accuracy and compliance.

• Validates accuracy and appropriateness of letters and other correspondence being sent to providers according to department guidelines.

• Validates payment of overturned cases for accuracy.

• Recognize and identifies possible training issues and error trends and reports findings to department management.

• Works with the Recovery Department for resolution of any identified overpayments.

• Assists in preparing and reviewing cases for regulatory and other health plan audits.

• Validates integrity and accuracy of data outputs for all Provider Appeals and Dispute reporting.

• Recognize potential system issues and process improvements relating to provider appeals and dispute data.

• Prepares and submits PDR Specialists' monthly quality performance reports to management.

• Prepares and disseminates internal management reports accurately within required timeframes.

• Supports department initiatives in improving processes and workflow efficiencies.

• Adheres to all regulatory and company standards, as described in the Employee Handbook and departmental Policies and Procedures.

• Complies with company's time and attendance policy.

• Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.

• Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.) and teamwork.

• Performs additional related duties as assigned by management.

• Minimum Experience:

a. 3+ years auditing of medical claims or provider dispute experience preferably in health plan setting

b. 5+ years experience in examining all types of Medicare Part C (medical) claims and/or provider dispute and appeals processing.

• Education/Licensure:

a. High school completion or GED required

b. Bachelor's degree preferred

• Other:

a. Understanding of Medicare Advantage provider appeals and dispute process.

b. Ability to interpret provider contracts to ensure claims payment accuracy.

c. Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.

d. Understanding of different payment methodology such as Medicare PPS (MS-DRG, APC, etc.), Medicare Physicians fee schedule, Per Diem, etc., coding edits and coordination of benefits.

e. Understanding of Division of Financial Responsibility on how they apply to claims processing.

f. Excellent verbal and written communication skills, ability to speak effectively before groups of customers or employees of the organization.

g. Computer skills: Intermediate to Advance Microsoft Excel and Word; Microsoft Access and EZCAP experience preferred.

h. Reasoning skills: ability to apply critical thinking skills and common sense understanding to successfully interpret issues and develop resolution.

i. Ability to work under pressure and deliver.

j. Strong attention to detail and analytical skills

k. Excellent organizational skills and ability to multi-task

l. Ability to work independently.