AMERICAN SPECIALTY HEALTH, INC.

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Claims Quality Review Analyst

at AMERICAN SPECIALTY HEALTH, INC.

Posted: 8/3/2019
Job Reference #: *4778196B9D68A8B0
Keywords: quality

Job Description

Requisition Number
19-0415

Post Date
7/23/2019

Title
Claims Quality Review Analyst

City
San Diego

State
CA

Description

American Specialty Health, Inc. is seeking a Quality Review Analyst to join our department. This position will perform audit and quality review processes in accordance with Claims Department Policy & Procedures.

You are invited to learn more about American Specialty Health’s events on our events page.

Responsibilities

  • Coordinates and conducts quality review of claims processing.
  • Conducts random quality review daily.
  • Conducts Contract Approval audits including Client Summaries and Fee Schedules.
  • Prepares and presents feedback on deficiencies identified in accuracy, timeliness, or quality to Claims Supervisor.
  • Identifies unique issues and problems within assigned areas of responsibility. Researches and formulates solutions in conjunction with Claims Supervisor.
  • Analyze and validate claim audits, health plan and state specific reporting.
  • Processes claims requiring special handling.
  • Reviews and releases aged claims on daily Pend Report.
  • Performs audit on new staff to ensure 100% accuracy.
  • Maintains confidentiality of all claims files, audit reports, and related claims data.
  • Develops and maintains reporting guidelines and specifications.
  • Prepare standardized weekly and monthly KPI reports.
  • Prepares applicable reports necessary to complete the KPI Reports.
  • Prepares and distributes daily reports to leadership, including but not limited to no-line items, pended claims, and 10-day TAT.

Qualifications

  • High School Diploma required.
  • Achieved progression to Level II Claims Examiner for internal Claims candidates, or minimum 2 years of experience performing claims processing or analyst/research duties.
  • Must be able to type 10,000 keystrokes per hour, either alpha-numeric or numeric with 95% accuracy or higher.
  • Advanced experience with MS Word, Excel and Access.
  • Knowledge of managed care operations, accreditation guidelines and state requirements.
  • Strong analytical and problem-solving skills.