Quality Control Reviewer II

1199seiu; New York (NY); On-site; USD 52,000 - 74,000; Full time

Job summary

1199SEIU is seeking a dedicated hospital claims processor to monitor and ensure accuracy in the claims workflow using the QNXT system. You will review document management inquiries, respond to provider questions, perform adjustments and refunds, and collaborate with management on complex denials and appeals; excellent written communication is required.

This on-site role demands strong organizational skills, attention to detail, and the ability to prioritize under tight deadlines in a fast-paced

Qualifications

• Minimum 2 years hospital claims processing experience.
• Strong knowledge of eligibility systems, COB guidelines and hospital claims.
• Proficient in Excel; MS Word preferred.

Responsibilities

• Monitor claims processing system (QNXT) to ensure functionality of hospital claims processing.
• Ensure timely/accurate processing of hospital claims according to SPD guidelines and related programs.
• Conduct system testing for QNXT upgrades and enhancements.
• Review DMS inquiries and medical records for accuracy; determine actions to rectify claims.
• Respond in writing to provider inquiries regarding claim adjustments/denials.
• Resolve call tracking tickets and escalated emails promptly.
• Perform adjustments and request refunds; update memos on payments.
• Request refunds for erroneous payments from providers and members.
• Process and evaluate facility claims manually or via DMS.
• Apply overpayments/refunds as directed by QA department.
• Resolve complex issues involving first and second level appeals.
• Perform additional duties/projects as assigned by management.

Skills

Communication skills

Organizational skills

Analytical skills

Multitasking

Time management

Education

High School Diploma or GED

Tools

QNXT

DMS

Microsoft Excel

Microsoft Word

Job description

Responsibilities

• Monitor claims processing system (QNXT) to ensure functionality of Hospital claims processing (i.e electronic, imaging, eligibility downloads from V3, pricing verification and pay-to-assignments)
• Ensure timely/accurate processing of hospital claims according to Claims Xten, Lab Management, Radiation Therapy, High-End Imaging, Medical Oncology and Specialty drug programs (i.e eviCore and CareContinuum); Summary Plan Description (SPD) guidelines, member benefits/eligibility parameters pre-authorization requirements; Fund policies and contracted/repricing rates
• Conduct system testing as it relates to QNXT upgrades, system enhancements and review performance of automated software
• Review Document Management System (DMS) inquiries/reconsiderations/medical records for accuracy, claims spreadsheets and determine action needed to rectify and resolve claims
• Respond in writing to provider inquiries/reconsiderations regarding claim adjustments/denials
• Resolve call tracking tickets and escalated e-mails in a timely manner
• Perform adjustments (related to inquiries, MedReview focused/revised DRGs Care Allies retrospective determinations); request credit refunds from provider and members; update member/claim memos regarding payment adjustments (overpayments and refunds)
• Request refunds for erroneous payments from providers and members
• Process and evaluate facility claims manually or through DMS
• Apply overpayments and refunds received and reported by the Claims Quality Assurance Department
• Resolve complex issues involving: 1st and 2nd level appeals
• Perform additional duties and projects as assigned by management

Qualifications

• High School Diploma or GED required, some College or Degree preferred
• Minimum (2) two years hospital claims processing experience required
• Strong knowledge of eligibility system, Coordination of Benefits (COB) guidelines and hospital claims processing required
• Intermediate knowledge of Microsoft Excel required; MS Word preferred
• Excellent communication skills both oral and written required; able to initiate correspondence and respond to inquiries in a clear and professional manner
• Ability to prioritize and work under pressure, with strict timelines and target dates
• Strong organizational and analytical skills with the ability to multi-task and follow up
• Good problem-solving skills with the ability to work independently and be a team player