Quality Assurance Lead

Job Title : Quality Assurance Lead

Have you got what it takes to succeed The following information should be read carefully by all candidates.

Department : Operations - Claims SoCal

About the Role :

Under the general direction of the Claims Compliance Manager, the Director of Claims Operations and / or Director of Operations, this position will be responsible for performing routine and complex audits of claims payment for pre- and post-check run.

The Quality Assurance Lead will summarize findings and provide recommendations to the reporting Supervisor / Manager as well as the Director of Claims Operations and Director of Operations.

The position is expected to clearly understand the products & healthcare benefit services offered to the capitated members that we manage, including the division of financial responsibility, as well as the associated limits and regulatory rules and guidelines.

The Quality Assurance Lead will ensure that the claims are adjudicated in accordance with State, Federal, Health Plan, and Network Medical Management guidelines.

What You'll Do :

• Lead and conduct pre-pay and post-pay audits to ensure accurate claims payments and denials for all levels of examiners and to capture deficiencies in processed claims prior to check run.
• Advanced knowledge in, and knows how to use and apply Health Plan Benefit Matrices and DOFR (Division Of Financial Responsibility).
• Lead the correction of claim adjudication errors.
• Test and audit new releases of Medicare and Medi-Cal Fee Schedules, provider payment pricing methodologies based on contract agreements.
• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to health plan operations or as documented in company policies and procedures.
• Advanced understanding of AB1455 Claims Settlement Practice & dispute and resolution regulations.
• Be able to understand and interpret the types of provider contracting arrangements and / or benefits administration data elements that need to be configured in the appropriate applications to support the accurate & timely payment of claims.
• Maintain knowledge of all ICD-9, CPT, HCPC codes, general billing procedures for health care providers and institutions, as well as Medicare and Medi-Cal reimbursement guidelines.
• Knowledge and understanding of rate application for all outpatient and inpatient facility, ASC, APR-DRG, DRG, interim rate, 3M Core Grouping, and CMAC rates of payment methods to appropriate line of business (Medicare, Medi Connect, Commercial, and Medi-Cal).
• Lead in the identification of any incorrect billing, coding, NCCI edits, duplicate payments, and incorrect payment adjudication.
• Test and audit claims payments for accuracy against contract information loaded into EZCAP and provide summary results to management.
• Generate and utilize audit reports for identifying claim adjudication errors.
• Document each individual review process, justification, and conclusion.
• Track and analyze claims adjudication errors.
• Advise and recommend solutions to drive improvement.
• Identify trends and work with claims management to develop action plans and metrics to ensure consistency of processing across the operations area.
• Makes recommendations for process improvement initiatives.
• Ensure that the Quality Auditing program is working as intended and make adjustments where necessary.
• Constant collaboration with the Claims Trainer to ensure that we are training based on identified error trends.
• Assist with the auditing of our automation queries.

Qualifications :

• Four years claims experience preferred including adjustments and auditing.
• Knowledge of MS Word, Excel, EZcap, Virtual AuthTech, Encoderpro and other basic medical terminology is required.
• Accepts change as a normal part of doing business, maintains a positive attitude, and exhibits constructive work behaviors during periods of transition.
• Meets work and attendance expectations; informs others in advance when commitments cannot be fulfilled.
• Actively supports organizational goals and values; aligns actions around organizational goals; gives priority to organizational needs and concerns when making decisions.
• Takes a reasoned logical approach in making judgments and decisions, carefully reviews available facts and information before reaching any conclusions.
• Identifies and gathers relevant information, consults the right people, and asks the right questions in a given situation.
• Demonstrates disciplined thinking that is clear, unbiased, analytical, and informed by evidence.
• Effectively communicate with others.
• Minimum high school diploma or GED is required.
• Minimum of four (4) years of experience in healthcare claims processing, including either adjustments, provider dispute resolution, and / or auditing.
• HCPCS, CPT, ICD10 coding experience is required.
• Knowledge of Medicare, Medicaid, or commercial insurance is needed. Knowledge of various payment and pricing methodologies.
• The ability to deal with confidential information is essential.
• Excellent verbal and written communication skills, including the ability to effectively communicate with internal and external customers.
• Excellent computer proficiency in MS Office products including expertise in MS Excel (creating spreadsheets and using advanced formulas) and PowerPoint.
• Must be able to work under pressure and meet deadlines, while maintaining a positive attitude and providing exemplary customer service.
• Ability to work independently and to carry out assignments to completion within parameters of instructions given, prescribed routines, and standard accepted practices.
• Understands and is able to apply insurance laws and regulations.

You're great for this role if :

• Coding certification is preferred.
• Has EZCAP experience.

Who We Are :

Astrana Health (NASDAQ : ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner.

Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient.

Our platform currently empowers over 10,000 physicians to provide care for over 1 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.

Our Values :

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

Environmental Job Requirements and Working Conditions :

• This position is remotely based in the U.S.
• The total compensation target pay range for this role is : $65,000 - $70,000. The salary range represents our national target range for this role.

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.

All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.

com to request an accommodation.

Additional Information :

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

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