Claims QA Analyst

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AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Claims QA Analyst in Miami and/or Gainesville, Florida. This is a hybrid position, 2 days in office and 3 days remote.

Scope of position: The Claims QA Analyst conducts audits of AvMed, Delegated Vendors, and Business Process Outsourcing (BPO) claims. The Claims QA Analyst conducts claims audits and works closely with the BPO to identify and correct any audit findings.

Essential Job Functions:

• Performs audits, analyzes system errors, identifies problems, and initiates corrective actions and preventative actions to ensure quality standards are in compliance with Federal and State regulations (CMS, DOI, AHCA, etc.) and AvMed policies and procedures. Coordinates with BPO and Delegated Vendors to finalize audit findings. Works with NTT to identify system errors and ensure that errors and claims impacted are corrected.
• Applies quantitative and qualitative analysis, maintains data integrity, and conducts quality improvement studies to support decision making, barrier analysis and implementation of interventions. Reviews any vendor initiatives established to ensure appropriate handling and compliance prior to development and implementation. Makes recommendation to Manager for approval.
• Conducts system testing, troubleshooting, implementation, and provides support to ensure business requirements are satisfied and configuration is accurate in contract and benefit configuration. Conducts random audit samples of manually and auto-adjudicated claims with an emphasis on claims payment and processing accuracy.
• Represent Manager in meetings.
• Provides with comprehensive claims analysis to management.
• Provides feedback on current procedures for efficiency and accuracy and assist supervisor in identifying additional training needs as result of their audit findings.
• Performs additional duties and responsibilities as assigned by management.

Minimum Requirements:

• Associates required
• Bachelor's in health sciences or similar concentration preferred
• 6-10 years of experience in a complex managed care environment with multiple products and entities, with an emphasis in claims, pricing and/or benefits. Previous audit or system configuration experience preferred
• An equivalent combination of education and experience may be considered

Preferred Requirements:

• Strong verbal and written communication skills
• Strong analytical and interpretative skills
• Excellent organizational skills
• Effective problem-solving skills and ability to handle simple and complex tasks
• Detail-oriented skills to adapt to various workflows, multiple tasks, deadlines and changing priorities
• Medical Coding including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-10) and Diagnosis-related Group (DRG) Codes
• HRP, MACESS, or Similar Software Systems
• Microsoft Office Suite (Word, Excel, Access)

Our Benefits: As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to:

• Medical, Dental, and Vision Insurance
• Paid Annual Leave, Sick Leave
• Flexible Spending Accounts
• Retirement funds with matching contribution
• Supplemental insurance policies, including legal, Life Insurance and AD&D among others
• Work Perks program including discounted movie and theme park tickets among other great deals
• Opportunities for further advancement within our organization

Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Benefits - Sentara (sentaracareers.com) Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, and growth! Note: Sentara Healthcare offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.

Keywords: Talroo-Health Plan, #INDEED, Auditing, Claims, Configuration

Expected to work closely with the Manager, other clinical and QI staff to assure the overall success of the Healthcare Effectiveness Data and Information Set (HEDIS) Project, appropriateness of care and other QI Projects as assigned. Primarily responsible for conducting medical record reviews, data entry and abstraction of data for HEDIS measures, appropriateness of care and other quality initiatives to meet regulatory and contractual requirements for the health plan. Must possess the knowledge to determine the appropriateness of care according to Virginia Medicaid standards. Bachelor's level degree in nursing (BSN) required for positions in Quality and Behavioral Health departments. Master's level degree in Social Work, Psychology or Counseling for Behavioral Health departments in lieu of BSN, with LCSW, LPC or LMFT required.

• Licensed Professional Counselor (LPC) - State license - North Carolina
• Licensed Professional Counselor (LPC) - State license - Other/National
• Licensed Professional Counselor (LPC) - State license - Virginia
• Registered Nurse (RN) Single State - Nursing License - North Carolina
• Registered Nurse (RN) Single State - Nursing License - Virginia
• Driver License - Certification - North Carolina Division of Motor Vehicles (NCDMV)
• Driver's License - Certification - Other/National
• Driver License - Certification - Virginia Department of Motor Vehicles (VDMV)
• Licensed Clinical Social Worker (LCSW) - State license - North Carolina Social Work Certification and Licensure Board (NCSWCLB)
• Licensed Clinical Social Worker (LCSW) - State license - Virginia
• Licensed Marriage and Family Therapist (LMFT) - State license - North Carolina
• Licensed Marriage and Family Therapist (LMFT) - State license - Virginia

• Bachelor's Level Degree
• Master's Level Degree
• Master's Level Degree
• Master's Level Degree

• Clinical 3 years

• Microsoft Office