The Claims Quality Control Auditor ensures organizational claim processing complies with contractual and regulatory requirements.
The position performs audit functions for internal and external clients, provides training standards based on findings; creates statistical auditing reports for management;
identifies trends and potential issues with claims processing, and recommends process improvements to maximize accuracy.
Duties and Responsibilities
Responsibilities include, but are not limited to the following :
- Review Neighborhoods claim process functions, including auto-generated adjudicated claims, based on provider and health plan contractual agreements and claims processing guidelines.
- Adheres to internal processes / procedures that ensure claim auditing functions comply with company policies and procedure standards.
- Advises and assists external departments with claims research and processing issues.
- Prepares statistical audit reports on audit findings, scores and corrective actions.
- Document and communicate claim issues identied during QC process and notify appropriate staff.
- Identifies root cause analysis for claim errors, and collaborate with internal and external departments to develop and implement solutions for resolution.
- Monitor claim error corrections reported in the audits.
- Report claims with suspected fraud, waste and abuse to management, and submits referrals to Special Investigation Unit.
- Meets with training department and claims management to recommend training related to QC reporting.
- Other duties as assigned.
- Corporate Compliance Responsibility - Responsible for complying with Neighborhoods Corporate Compliance, Standards of Business Conduct, applicable contracts, laws, rules / regulations, policies and procedures as it applies to individual job duties, the department, and Company.
This position exercises due diligence to prevent, detect and report unlawful and / or unethical conduct by fellow co-workers, professional affiliates and / or agents
Claims Quality Control Auditor (35027)
The Claims Quality Control Auditor ensures organizational claim processing complies with contractual and regulatory requirements. Review Neighborhoods claim process functions, including auto-generated adjudicated claims, based on provider and health plan contractual agreements and claims processing ...
Senior Manager of Quality Improvement and Analysis
The Senior Manager of Quality Improvement and Analysis is Neighborhood's organizational lead for implementing all facets of the Healthcare Effectiveness Data and Information Set (HEDIS), Medicare Stars and related quality measurement and monitoring activities for all product lines. This position mus...
Senior Quality Assurance Automation Engineer
Mainframe Senior Test Automation Engineer. Develop and maintain test automation frameworks to ensure the quality and reliability of distributed applications across multiple layers of the technology stack. Work independently as part of Agile Sprint and Kanban teams to deliver high-quality software so...
Senior Quality Engineer
As the Senior Quality Engineer, you will play a crucial role in ensuring that all products are manufactured to meet the highest quality standards. Your responsibilities will include managing the Quality Management System (QMS), overseeing cleanroom operations, leading validation initiatives, and dri...
Quality Welding Inspector @ Cumberland, Rhode Island (1099 Contractor)
Experience as a quality inspector, experience in material receipt inspection and weld inspector for ASME BPE production welding. Material receipt inspection and weld inspector for ASME BPE production welding. Conducts quality control inspections of in-process and pre-shipment products at local facil...
Quality Inspector $19
Quality Inspector $17 - 20/hr DOE. Experience performing Quality inspections on small pieces - Perform visual and dimensional inspections on machined components. Since 1985 we have taken great pride in providing quality staffing services to businesses in the fields of Information Technology, Enginee...
Bilingual-Temp Quality Assurance Specialist
Assist the Quality/Training Manager and Assistant Manager with administrative functions, including developing Standard Operating Procedures (SOPs), Quality Standard Definition Document (QSDD), Quality Forms, and coordinating quality recognition programs. As a Temporary Quality Assurance Specialist w...
Quality Manager - Aerospace Manufacturing Industry; Bristol, RI
The Quality Manager will also have direct supervision over the quality department at the site including quality engineers, technicians, and screeners. The Quality Manager (Bristol Site) will work in concert with their teams towards 100% customer satisfaction by implementation of an effective quality...
Quality and Accreditation Specialist
The Quality and Accreditation Specialist (QAS) reports to the Director of Quality Accreditation and Regulatory Readiness. The QAS will work collaboratively with all clinical programs disciplines within Gateway Healthcare across all sites and regions to support the implementation of the overall Quali...
Manager, Supplier Quality
Aspen is looking for an engaging, motivated, and inspirational Supplier Quality Manager to drive Aspen’s quality culture forward in the aerogel manufacturing business as well as its supply Supplier Quality Manager will report to the Quality Manager – Aerogel Manufacturing. The Supplier Quality Mana...