Position Purpose:

Performs complex (journey-level) quality audit work. Audits of claims/dispute resolutions to ensure compliance with contract requirements and performs user testing and interface with the required systems. Works under general supervision, with moderate latitude for the use of initiative and independent judgement.

Essential Responsibilities:

• Performs audits and examinations of case files to identify inaccuracies and non-compliance issues.
• Shares educational feedback, trends and insight individually and collectively with the staff.
• Performs data analysis to identify improvement opportunities in the appeals/dispute resolution process
• Provides quality and analytical support to the department including assisting senior analyst in data interpretation and preliminary analysis.
• Prepares training materials and provides technical training to employees.
• Assesses the training and monitors the effectiveness of the information delivered.
• Provides training based on system updates.
• Monitors the system availability and analyzes any potential impacts to the organization.
• May perform system maintenance and testing and is a corporate representative to the System User Group.
• Participates in special projects and performs other duties as assigned.

Minimum Qualifications

Education

• High School Diploma or equivalent

Experience

• Three (3) years of general office experience
• College education or technical training in administration, business, or related areas may be substituted for experience on a year per year basis. (Education requirements may be satisfied by full-time education or the prorated part-time equivalent.)
• One (1) year of Qualified Independent Contractor (QIC) appeals or other healthcare appeals processes
• Patient versus Provider Dispute Resolution and Independent Dispute Resolution (Provider vs Insurer), preferred

Knowledge, Skills and Abilities

Considerable Knowledge of

• Research techniques
• Medicare program
• Applicable systems and applications
• Applicable laws, rules and regulations

Proficient Skill in

• Developing and giving presentations and trainings

• Prioritizing and organizing work assignments

• Researching, analyzing and interpreting policies and state and federal laws and regulations

Ability to

• Multitask and meet deadlines
• Exercise logic and reasoning to define problems, establish facts and draw valid conclusions
• Make decisions that support business objectives and goals
• Identify and resolve problems or refer issues appropriately
• Communicate effectively verbally and in writing
• Adapt to the needs of internal and external customers
• Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards
• Assures compliance with company policies and procedures, including regulatory, contractual and accreditation entities