Claims Quality And Support Associate

Responsibilities

• Review and inspect operational claim processes and adjudication to apply quality standards.
• Create clear audit findings and recommendations in written audit processing status codes, provide feedback to examiners used in examiner score cards, and identify error trends and training opportunities.
• Understand, interpret, and apply coding and reimbursement guidelines; provider and health plan contracts for professional claims to ensure accuracy.
• Audit, assess, and monitor providers and payers (physicians, inpatient, outpatient, ancillary, behavioral healthcare, laboratory, etc.), including independent coding and abstraction of medical records.
• Analyze inpatient and outpatient medical records using ICD-9/ICD-10, CPT, HCPCS, UB, and other codes, ensuring compliance with regulatory and contractual requirements.
• Verify and validate claims documents received through multiple channels, ruling out documentatio...