Claims Quality Analyst

Empower. Unite. Care.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

MetroPlus Health provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus Health 's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus Health has been committed to building strong relationships with its members and providers.

Position Overview

Claims Quality Auditor is responsible for reviewing claims to determine if payments have been made correctly. This position analyzes data used in settling claims to determine the validity of payment of claims and reports overpayments, underpayments and other irregularities based upon benefit configuration, compliance with provider contract agreements, and Federal, State and Plan’s established guidelines and / or policies and procedures. The incumbent will research, review, and suggest process improvements, training opportunities and is a resource of information to all staff. The incumbent will also perform special projects.

Work Shifts

9 : 00 A.M – 5 : 00 P.M

Duties & Responsibilities

• Audit daily processed claims through random selection based on set criteria.
• Document, track, and trend findings per organizational guidelines
• Based upon trends, determine ongoing Claims Examiner training needs, and assist in the development of training curriculum.
• Conduct in-depth research of contract issues, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends. Recommend actions / resolutions.
• Work with other organizational departments to develop corrective action plans to improve accuracy of the claims adjudication processes and assure compliance with organizational

requirements and applicable regulations

Minimum Qualifications

Professional Competencies

Benefits

NYC Health and Hospitals offers a competitive benefits package that includes :

#LI-Hybrid

#MHP50