Claims Quality Support Officer

What we do

The Claims Quality & Support Officer responsible for activities concerned with review and inspection to  apply quality standards for operational claim processes and adjudication.

What you bring

• Prepare concise documentation and audit reports, including recommendations to claims management for improvements with corrective action plans;
• Audit, assess, and monitor providers and payers, to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral healthcare, laboratory, etc. medical records, and independently codes, and abstracts.
• Analyze inpatient and outpatient medical records using most current International Classification of Diseases (ICD-9/ICD-10),Current Procedural Terminology (CPT), Health Care Common Procedure Coding System (HCPCS), Universal Billing (UB) and other codes, regulatory and contractual requirements, and generally accepted coding practices.
• Verify and validate claims documents received through multiple channels to rule out possibility of documentation / coding errors or other inconsistencies that may occur in case of suspected fraud and abuse cases.
• Special focus and priority will be given to regulatory audit requirements, reports and findings.
• A summary of findings will be issued on monthly basis through a report, including recommendations on changes to be made, aligned with the Claims Quality Manager
• Any other task required by the manager, within the scope of Audit and Claims Support

What we require

• Bachelor’s Degree (Medical Degree or Nursing)
• Minimum 5 years’ experience from Providers/TPA’s in processing/adjusting claims (e.g. ICD-9/10, CPT, HCPC) or Minimum 3 years’ experience auditing experience
• Demonstrated understanding of medical claims processes and procedures, and ability to recognize and interpret variances
• Legally permitted to work in the country of operations.
  Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills

Job Location

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