Quality Control Analyst - Medical Claims

Job Description:

The Quality Control Analyst is responsible for claims auditing and identifying examiner and system errors. This position also handles the auditing of claims special projects including risk pool, shared risk, Health Plan.

Duties and responsibilities:

• Understands, interprets and applies coding and reimbursement guideline; provider and Health Plan contracts for professional claims to ensure accuracy. Review of complex and high dollar claims to determine financial and risk accuracy and in depth review of written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers.
• Identifies potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments
• Creates clear and accurate audit findings and recommendation in written audit processing status codes that provides feedback to examiners used in examiner score card, identifies error trends and training opportunity.
• Audits system configuration for new client implementation and provider or Health Plan contracts and amendments.
• Retrospective auditing of paid claims on a quarterly basis. This includes flagging of overpaid claims for recovery.

Required Educational Attainment and Work Experience:

• Bachelor’s degree in Finance or Accounting or equivalent experience.
• High school diploma or equivalent required
• 5 years of experience as a Quality Control Analyst.
• 2-3 years of experience as Claims Adjuster

Working Conditions:

• Amenable to work in Bridgetowne, Quezon City
• Willing to work in a nightshift schedule.

Company Benefits:

• HMO plus free dependents
• Group life insurance
• PTO Credits
• Annual Appraisal
• Annual Performance Bonus