Job Description:
• Conduct quality audits of A&G items including grievances, pre-service appeals, and post service appeals utilizing appropriate sources of information; including eligibility, claims, authorizations, service forms, faxes, and any additional information required to complete the request.
• Analyze errors and determine root causes for appropriate classification, trending, and remediation.
• Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure quality.
• Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and fully resolved in a compliant manner.
• Present results of investigations to senior staff and prepare written reports concerning investigation activities.
• Subsequent auditing and handling of specific appeal and grievance requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.
• Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.
• Assist in the development of departmental policies and procedures; reviews the efficiency of existing training.
• Meet established time frames and rates of performance for the quality and quantity of work for the position.
• Participate in regulatory and mock audit activities including universe review, universe scrubbing, risk analysis, timeliness assessment, and case walkthrough activities.
Requirements:
• Experience with the investigation, resolution, and reporting of appeal and grievance processes.
• Experience in Microsoft Office suite of applications including Excel (formatting formulas, managing data, and filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations).
• High School Diploma or GED from an accredited institution.
• Associate degree from an accredited institution (preferred).
• ICD10 certification (preferred).
• Experience in an Auditing capacity conducting root cause analysis (preferred).
• Knowledge of at least two or more lines of business such as Medicare NY/NJ, Medicaid, Family Health Plus, Child Health Plus, NH Family (preferred).
• Experience handling confidential information.
Benefits:
• medical, dental and vision coverage
• incentive and recognition programs
• life insurance
• 401k contributions
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