Claims Quality Assurance Analyst
Location: Pearland Administrative Office
Department: Claims Administration
Job Type: Full Time
Kelsey-Seybold Clinic. Your Doctors for Life.
Since 1949, Kelsey-Seybold Clinic has served its patients with one goal in mind – combine the expertise of physicians in a variety of medical specialties, with the close personal care of a family doctor. Kelsey-Seybold is Houston’s largest community-based physician group, caring for more than 400,000 patients. With 19 clinic locations, we are growing to meet the health care needs of our diverse patient population. Our mission is to provide our team members with exceptional opportunities for professional and personal growth.
Position will primarily support all Managed Care Quality Improvement initiatives. Primary responsibilities include:
QI performance of unit/system processes including: HPE Audit, Background Adjudicator, Claim Service (Adjustment review/list), Provider Service CRM Topic, Create provider specific reports, perform high dollar claims analysis and monthly purchase service analysis. Responsibilities include review/assess work flow processes including polices & procedures for each unit. Audit performance of applicable tasks. Identify Performance gaps. Additional responsibilities include: Claims testing support for system upgrades and implementations. Identify discrepancies (i.e. overpayments/underpayments, contract build, benefit build). Assist with QI documentation. Assist with training documentation relative to EPIC Tapestry services (Claims Adjudication, CRM-Customer-Relationship Module for Claims, Provider Services, Coordination of Benefits, Appeals and Claim Services.) Assist with training/ orientation of both facility and professional claims adjudication. Assist with training and development as needed.
EDUCATION REQUIREMENTS & EXPERIENCE REQUIREMENTS
(A = basics; B = preferred)
Associates Degree or Diploma with equivalent industry experience
Word processing experience, must be proficient with Microsoft Word, familiar with Excel, Access and Power Point
Strong orientation to customer satisfaction processes. Self-motivated. Able to work independently of direct supervision.