Ucdp Of California, Inc.
Job Description :
The Quality analyst reviews inquires to determine if they meet the definition of a grievance/appeal. Documents, investigates, refers and coordinates grievances and appeals. Initiates a case file for each grievance and appeal. Ensures compliance with organizational and regulatory requirements for member or provider issues. Independently coordinates to resolution with internal/external parties as required; and documents and summarizes to all parties involved in the case the investigation results.
1. Ensure the consistent, accurate, efficient, and appropriate processing of adjustments and/or duplicate claims through an audit sampling review process.
2. Develop management reports detailing the review process findings as well as trending/analysis reports
3. Monitor and train quality and operational staff
4. 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
5. Other duties as assigned or requested.
Education, Licenses/Certifications, and Experience
- High School Diploma/GED
- 3-5 years of relevant, progressive experience in the area of specialization. Exempted experience requirements effective August 2016.
- 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 job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
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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