Claims Quality Assurance Analyst (Remote)

LOCATION: Remote – this is a home based, virtual position that operates from Monday – Friday from 8:30am-5:00pm (EST). Vaya Health welcomes applications from NC, SC, GA, TN, VA, MD, and FL.

GENERAL STATEMENT OF JOB

This position is responsible for performing thorough quality reviews on a weekly basis of work processes performed in the Claims and Reimbursement department for accuracy and completeness. The position identifies trends and patterns in claim and eligibility work products and provides feedback on findings to department management to support ongoing coaching, training and process improvement. The position supports onboarding of new employees during the onboarding phase to assist department leadership with coaching, feedback and training to develop new employees.

Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

ESSENTIAL JOB FUNCTIONS

Conduct Internal Quality Audits: 

This position will audit a random sample of work performed by claim and enrollment specialists on a weekly basis to evaluate staff understanding of the steps needed to resolve external and internal customer requests; and evaluate use of the appropriate standard operating procedures and tools to complete work tasks in an accurate, complete, and timely manner. Accurately document quality reviews by work type and functional areas within the department in a detailed and timely fashion. Utilize guidelines defined in the department Standard Operating Procedures (SOPs), and workflows to evaluate the quality of completed work products. Conduct weekly onboarding audits for new employees during the onboarding phase to assist direct supervisors with timely feedback and coaching.

Prepare and Maintain Audit Findings:

Provide timely feedback to manager and department leaders on audit findings based on established department guidelines. Provide recommendations for new or modified processes and procedures to address processing accuracy errors. Prepare audit reports for internal business partners as needed and serve as the subject matter expert for quality audit questions. Track and champion open audit items and work with manager and team supervisor to advocate for timely resolution. Utilize audit findings and trends to provide training support to business units within the department as needed. 

Collaboration with other Vaya Departments:

This position will work with internal business partners to identify gaps in desk level procedures, identify system deficiencies affecting quality audit processes and monitor for resolution. 

Other duties as assigned.

KNOWLEDGE, SKILLS, & ABILITIES 

• Ability to tactfully communicate audit results when providing feedback to co-workers, supervisor, and managers
• Strong attention to detail and data accuracy 
• Strong computer skills and the ability to learn additional databases and review multiple applications and/or screens at one time
• Must have strong time management skills
• Must have efficient and effective verbal and written communications and listening skills.
• Ability to make quick and effective independent decisions
• Ability to problem-solve, and resolve challenges in a timely, professional manner
• Excellent written and oral communication skills
• Can work independently, and with a team, to meet deadlines
• Must be proficient in the following software applications: Microsoft Word, Excel, Outlook, and SharePoint
• Must be proficient or able to quickly learn the organization’s claims adjudication system and NC Tracks or any other multi-payer management information system for NC Department of Health and Human Services
• Knowledge of claims adjudication processes, provider contracting and credentialing and member eligibility and the impact of these three functional areas working collaboratively to support successful claims processing
• Well-developed understanding of the health insurance industry and an in-depth understanding of healthcare data analysis

EDUCATION & EXPERIENCE REQUIREMENTS

High School Diploma or GED with at least 5 years of combined experience in health care claim processing specifically Medicaid, Medicare and other 3rd party payment sources –OR— an Associate Degree in a related field (preferred) with a combination of 2 years of post-degree experience in health care claim processing specifically Medicaid, Medicare and other 3rd party payment sources.

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. 
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. 
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. 
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: The person in this position must live in NC, SC, GA, TN, VA, MD, or FL.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled.

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.