Gateway Health Plan
Job Description :
This job is responsible for compiling and analyzing data relevant to the handling of all types of complex adjusted claims; conducting reviews of all organizational or functional activities related to fraud/abuse perpetrated by providers, subscribers, facilities, pharmacies, provider employees and/or employees of the company and ensuring the Organization’s compliance with all adjustment processes based on SOX remediation and Regulatory and legal guidelines. In addition, the incumbent will identify potential areas of processing vulnerability through procedure review and report trending/analysis; generate reports for analysis and/or sampling; review audit samples for accuracy and appropriateness; train operational staff on processes, act as the subject matter expert for all audit adjustment processes for workgroups, recommend and implement process changes, and coaching quality review staff. As a result of the analysis and sampling activity, the incumbent will develop reports detailing the findings and trending results on a monthly basis while also recommending any processing enhancements and/or internal control improvements.
- Ensure the consistent, accurate, efficient, and appropriate processing of adjustments and/or duplicate claims through an audit sampling review process.
- Develop management reports detailing the review process findings as well as trending/analysis reports.
- Monitor and train quality and operational staff.
- Identify any potential fraudulent activity relating to adjustment and/or duplicate claim processing and address any and all deficiencies to remain compliant and report non compliant areas.
- Other duties as assigned or requested.
- High School Diploma/GED
- 5-10 years of relevant, progressive experience in the area of specialization
- Experience in claims and/or inquiry processing or equivalent experience in quality
- Experience with Microsoft Office Products
Knowledge, Skills and Abilities
- Detailed understanding of the various claims and inquiry processing arrangements, the related Member Touchpoint Measures (MTM) performance standards, and process improvement methodologies
- Working knowledge of various company related benefits, payment policies and procedures, medical terminology, profile mechanisms, and medical policy guidelines
- Strong background in both verbal and written communication, interpersonal skills, and organizational, problem solving, analytical, interpretative, evaluative and creative skills and abilities
- Proficiency with reporting and analytical software tools and a strong knowledge of systems utilized throughout the company Operations Division
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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