Quality Control Reviewer II

Job Title

Responsibilities

Monitor claims processing system (QNXT) to ensure functionality of hospital claims processing (i.e electronic, imaging, eligibility downloads from V3, pricing verification and pay-to-assignments)

Ensure timely/accurate processing of hospital claims according to Claims Xten, Lab Management, Radiation Therapy, High-End Imaging, Medical Oncology and Specialty drug programs (i.e eviCore and CareContinuum); Summary Plan Description (SPD) guidelines, member benefits/eligibility parameters pre-authorization requirements; Fund policies and contracted/repricing rates

Conduct system testing as it relates to QNXT upgrades, system enhancements and review performance of automated software

Review Document Management System (DMS) inquiries/reconsiderations/medical records for accuracy, claims spreadsheets and determine action needed to rectify and resolve claims

Respond in writing to provider inquiries/reconsiderations regarding claim adjustments/denials

Resolve call tracking tickets and escalated e-mails in a timely manner

Perform adjustments (related to inquiries, MedReview focused/revised DRGs Care Allies retrospective determinations); request credit refunds from provider and members; update member/claim memos regarding payment adjustments (overpayments and refunds)

Request refunds for erroneous payments from providers and members

Process and evaluate facility claims manually or through DMS

Apply overpayments and refunds received and reported by the Claims Quality Assurance Department

Resolve complex issues involving: 1 st and 2 nd level appeals

Perform additional duties and projects as assigned by management

Qualifications

High School Diploma or GED required, some College or Degree preferred

Minimum (2) two years hospital claims processing experience required

Strong knowledge of eligibility system, Coordination of Benefits (COB) guidelines and hospital claims processing required

Intermediate knowledge of Microsoft Excel required; MS Word preferred

Excellent communication skills both oral and written required; able to initiate correspondence and respond to inquiries in a clear and professional manner

Ability to prioritize and work under pressure, with strict timelines and target dates

Strong organizational and analytical skills with the ability to multi-task and follow up

Good problem-solving skills with the ability to work independently and be a team player