Quality Control Reviewer III

1199seiu; New York (NY); On-site; USD 55,000 - 75,000; Full time

Job summary

1199SEIU in New York is seeking an experienced Hospital Claims Processor to cross-train staff and support the Fraud & Abuse findings in the Hospital Claims Department. You will review complex claims and ensure timely processing across multiple programs.

The role requires strong Excel skills, excellent written and verbal communication, and the ability to work under strict timelines. Collaboration with QA and management is essential.

Qualifications

• High School Diploma or GED required, some college or degree preferred.
• Minimum three years hospital claims processing required.
• Strong knowledge of eligibility system, COB guidelines and hospital claims processing.
• Intermediate knowledge of Microsoft Excel; MS Word preferred.
• Excellent written and oral communication required, professional correspondence.

Responsibilities

• Cross train Processors and Quality Control Reviewers in the Hospital Claims Department.
• Create advances from providers based on Fraud & Abuse findings.
• Review complex claim issues involving 1st, 2nd and 3rd level appeals (IPRO).
• Review and finalize claims according to Ceris findings.
• Monitor claims processing system (QNXT) to ensure functionality of hospital claims processing.

Skills

Excellent communication

Strong organizational skills

Analytical skills

Problem-solving

Multi-tasking

Team player

Education

High School Diploma or GED

Some College or Degree

Tools

Microsoft Excel

MS Word

Job description

Responsibilities

• Cross train Processors and Quality Control Reviewers in the Hospital Claims Department


• Create advances from providers based on the findings of the Fraud & Abuse Department


• Review complex claim issues involving 1st, 2nd and 3rd level (IPRO) appeals


• Review and finalize claims according to Ceris findings


• 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)


• Review and handle ESI/ eviCore corrected claim reports


• Review and correspond with Aetna P.O.S on specific requests


• 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


• Process and evaluate facility claims manually or through DMS


• 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


• Apply overpayments and refunds received and reported by the Claims Quality Assurance Department


• Perform additional duties and projects as assigned by management

Qualifications

• High School Diploma or GED required, some College or Degree preferred


• Minimum (3) three years hospital claims processing 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