Quality Control Reviewer II

Responsibilities

•       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)

•       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

•       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

•       Process and evaluate facility claims manually or through DMS

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

•       Resolve complex issues involving: 1st and 2nd level appeals

•       Perform additional duties and projects as assigned by management

Qualifications

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

•       Minimum (2) two years hospital claims processing  experience 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