Operational Support - Claims Review Analyst 139-1012

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 42,000 - 54,000; Full time

Job summary

CommunityCare HMO Inc. is seeking a quality reviewer to audit claims, enrollment, and customer service outputs against management criteria to ensure accuracy and compliance across processes.

Daily audits will require completing feedback forms for managers, coordinating with trainers on identified training needs, and addressing inquiries from staff. A high school diploma is required; an associates degree and four years of claims or quality review experience are preferred.

Qualifications

• Ability to read and understand claims processing manuals, CPT codes and perform claims processing procedures.
• Knowledge of claims processing manuals and health benefit booklets.
• Excellent interpersonal skills and the ability to work with individuals at all levels in the organization.
• Successful completion of Health Care Sanctions background check.
• Ability to perform detailed math calculations.
• Proficient in Microsoft Office applications.
• Self-motivated with the ability to handle multiple tasks, work independently with minimal direction and meet stringent deadlines.
• Possess strong oral and written communication skills.

Responsibilities

• Audit claims, enrollment and customer service personnel daily of randomly selected work and complete appropriate forms related to the audits.
• Answer questions for claims, enrollment and customer service personnel.
• Establish training needs for employees identified during the quality review process.
• Perform other job-related duties as assigned.

Skills

Claims processing

CPT codes

Interpersonal skills

Written communication

Math calculations

Self-motivation

Multitasking

Education

High school diploma or equivalent

Associates degree preferred

Tools

Microsoft Office

Job description

Job Summary

Perform quality review on claims, enrollment, and customer service personnel on select criteria determined by management. Audit personnel daily of randomly selected output and complete appropriate forms for manager/supervisor feedback. Will work closely with trainer on training needs identified through the quality review process.

Perform quality review on claims, enrollment, and customer service personnel on select criteria determined by management. Audit personnel daily of randomly selected output and complete appropriate forms for manager/supervisor feedback. Will work closely with trainer on training needs identified through the quality review process.

Key Responsibilities

• Audit claims, enrollment and customer service personnel daily of randomly selected work and complete appropriate forms related to the audits.
• Answer questions for claims, enrollment and customer service personnel.
• Establish training needs for employees identified during the quality review process.
• Perform other job-related duties as assigned.

Qualifications

• Ability to read and have a clear understanding of claims processing manuals, medical terminology, CPT codes and perform claims processing procedures.
• Knowledge of claims processing manuals and health benefit booklets.
• Excellent interpersonal skills and the ability to work with individuals at all levels in the organization.
• Successful completion of Health Care Sanctions background check.
• Ability to perform detailed math calculations.
• Proficient in Microsoft Office applications.
• Self-motivated with the ability to handle multiple tasks, work independently with minimal direction and meet stringent deadlines.
• Possess strong oral and written communication skills.

Education/Experience

• High school diploma or equivalent required. Associates degree preferred.
• Four years claim related processing experience.
• One to two years quality review/auditing experience preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin