Operational Support - Claims Review Analyst 139-1006

JOB SUMMARY:

Perform quality review on claims, enrollment, and customer service personnel on select criteria determined by management.  Audit personnel daily of randomly selected output and complete appropriate forms for manager/supervisor feedback. Will work closely with trainer on training needs identified through the quality review process.

KEY RESPONSIBILITIES:

• Audit claims, enrollment and customer service personnel daily of randomly selected work and complete appropriate forms related to the audits.
• Answer questions for claims, enrollment and customer service personnel.
• Establish training needs for employees identified during the quality review process.
• Perform other job-related duties as assigned.

QUALIFICATIONS:

• Ability to read and have a clear understanding of claims processing manuals, medical terminology, CPT codes and perform claims processing procedures.
• Knowledge of claims processing manuals and health benefit booklets.
• Excellent interpersonal skills and the ability to work with individuals at all levels in the organization.
• Successful completion of Health Care Sanctions background check.
• Ability to perform detailed math calculations.
• Proficient in Microsoft Office applications.
• Self-motivated with the ability to handle multiple tasks, work independently with minimal direction and meet stringent deadlines.
• Possess strong oral and written communication skills.

EDUCATION/EXPERIENCE:

• High school diploma or equivalent required. Associates degree preferred.
• Four years claim related processing experience.
• One to two years quality review/auditing experience preferred.