Claims Quality Control Auditor

Neighborhood Health Plan of Rhode Island; Smithfield (RI); On-site; USD 55,000 - 75,000; Full time

Job summary

Neighborhood Health Plan of Rhode Island is seeking a Claims Quality Control Auditor to ensure claims processing aligns with contractual and regulatory requirements. The role involves auditing both internal and external processes, producing statistical reports, and driving improvements to accuracy and provider satisfaction.

Responsibilities include reviewing auto and manual claims, identifying trends, and presenting findings to management.

Qualifications

• Experience in medical billing or claims processing.
• Ability to read and apply contract terms to claims processing and quality audits.
• Proficient in data analytics and Excel for reporting.

Responsibilities

• Review claim processing functions against provider and health plan contracts.
• Identify trends and errors, prepare written audit reports.
• Assist with root cause analysis and corrective actions.
• Participate in UAT and system upgrade reviews to ensure accuracy.
• Report suspected fraud, waste, or abuse as required.

Skills

Medical billing

Data analytics

Excel

Communication

Teamwork

Education

Associates Degree or equivalent

Tools

Cognos

Optum Encoder

Job description

The Claims Quality Control Auditor ensures organizational claim processing complies with contractual and regulatory requirements. The position performs audit functions for “internal and external” clients, provides training standards based on findings; creates statistical auditing reports for management; identifies trends and potential issues with claims processing, and recommends process improvements to maximize accuracy.Duties and ResponsibilitiesResponsibilities include, but are not limited to the following:Review Neighborhood’s claim process functions, including auto adjudicated and manually processed claims and issues, based on provider and health plan contractual agreements and claims processing guidelines.Adhere to internal processes/procedures that ensure claim auditing functions comply with company policies and procedure standards.Identify trends and patterns in errors and issues found during audit reviews and upchannel to appropriate management.Prepare written reports on audit findings, scores and corrective actions.Advise and assist external departments with claims research and processing issues.Identify root cause for claim errors, and collaborate with internal and external departments to develop and implement solutions for resolution of identified issueReview post impact analyses provided by Operations Support to ensure systems upgrades have been configured accurately. Provide written report to Business Analysts of review results. Review any problems found with appropriate Business Analyst.Create Master Impact Analysis (IA) for each processing system. This Master IA will be created from results of the weekly Claims Adjustment Committee meeting and be used by adjusters from each delegate to reprocess claims according to the respective configuration changes in each system.Participate in User Acceptance Testing (UAT). As such, perform analysis and review all upgrade information to ensure accuracy and completeness negating any future claims processing issues. Identify any errors in claims processing during this testing and provide input to the configuration teams involved.Complete any ad-hoc audits that approved by Claims management that are requested by upper management, legal, contracting, or any other party within Neighborhood.Identify and communicate ways to improve claims and systems processing accuracy and increase provider/member satisfaction.Report claims with suspected fraud, waste and abuse to management, and submits referrals to Special Investigation Unit.Other duties as assignedQualificationsRequired:Associates Degree or equivalent relevant work experience in lieu of a degreeMinimum 1-3 years directly related experience in medical billing or claim processingCapable of performing mathematical functions (i.e., calculations/discounts/interest commission/percentages, etc.)Intermediate to Advanced skills in Microsoft Office Suite (Excel, Outlook, Word)Data analytics experienceAbility to read understand and apply contract terms to claims processing and quality auditsExcellent communications skills allowing for the effective description of systems deficiencies and processing errorsAbility to work both independently and in a team-based environmentAbility to manage multiple projects simultaneouslyMust exercise excellent judgment and be effective working autonomously and as part of a teamExceptional listening skills and verbal/written communication skillsProblem solver with strong attention to detailPreferred:Certified Professional Coder (CPC) certification3+ years directly related experience in medical billing or claim processingKnowledge of COGNOS reporting environmentPrior experience with Optum Encoder or similar coding program/websitesNeighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.