Claims Quality Analyst

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

Claims Quality Auditor is responsible for reviewing claims to determine if payments have been made correctly. This position analyzes data used in settling claims to determine the validity of payment of claims and reports overpayments, underpayments and other irregularities based upon benefit configuration, compliance with provider contract agreements, and Federal, State and Plan's established guidelines and/or policies and procedures. The incumbent will research, review, and suggest process improvements, training opportunities and is a resource of information to all staff. The incumbent will also perform special projects.

Job Description

• Audit daily processed claims through random selection based on set criteria.
• Document, track, and trend findings per organizational guidelines
• Based upon trends, determine ongoing Claims Examiner training needs, and assist in the development of training curriculum.
• Conduct in-depth research of contract issues, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends. Recommend actions/resolutions.
• Work with other organizational departments to develop corrective action plans to improve accuracy of the claims adjudication processes and assure compliance with organizational
  requirements and applicable regulations
• Assist in the development of Claims policies and procedures
• Provide backup for other trainers within the department
• Assist in training of new departmental staffs
• Assist with the research and resolution of audit appeals
• Asist with external/internal regulatory audits
• Identify policies or common errors requiring retraining sessions.
• Participate in quality projects as required.
• Collect, analyze data, identify trends, write reports (i.e., the monthly and quarterly reports) and present findings to the appropriate claims service management personnel.
• Other duties as assigned by senior management

• Associate degree required; Bachelor's degree preferred
• Minimum of 4 years of experience performing claims quality audits in a managed care setting
• Expertise in both professional and institutional claims coding, and coding rules required.
• Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and standard industry reimbursement methodologies required.
• Strong knowledge of CMS Medicare and NYS regulations required.
• Experience in training development and presentation preferred
• Must have excellent interpersonal, verbal, and written communication skills

• Strong organizational, analytical, and oral/written communication skills required.
• Proficiency in PC application skills, e.g., excel, word, PowerPoint, etc.,
• Must be able to follow direction and perform independently according to departmental
• Integrity and Trust