Quality Assurance Specialist I

Viva Health•Birmingham, AL

7d•Hybrid

About The Position

The Quality Assurance (QA) Specialist is responsible for the overall development and implementation of quality assurance in an effort to provide customers with superior service. This role is responsible for auditing and reporting analysis of Claims and Entry staff, Commercial Customer Service phone queue calls, Medicare Member Services phone queue calls, System Configuration, and Provider/Fee Configuration.

Requirements

High School Diploma or GED
2 years’ experience with all components of claims processing, Medicare enrollment, and/or customer service
Knowledge of ICD9, CPT, HCPCS, HCFA, Uniform Billing codes, and Co-ordination of Benefits (COB)
Proficient in medical terminology
Demonstrate excellent customer service skills through written and verbal communication
Ability to prioritize and multitask while maintaining organization and attention to detail
Ability to work in a team environment, remaining flexible to ideas, routines and schedules, recognizing responsibilities, and actively participating with others to accomplish assignments and achieve desired goals

Nice To Haves

PowerSTEPP (TXEN) experience
Quality Assurance experience
Coding experience

Responsibilities

Review Claims Entry and Adjudication staff for accuracy based on applicable plan coverage documentation in accordance with departmental policies and procedures, company compliance plans, and all regulatory guidelines.
Document and distribute error findings to management for review.
Provide training and education to Claims Entry and Adjudication staff on claims payment issues to ensure claims are adjudicated in an effective and efficient manner.
Identify and report benefit configuration issues; communicate with internal departments to resolve problems that affect claim payment.
Investigate claim submissions for coding inaccuracies, review high dollar remittances for payment and benefit configuration accuracy.
Report overall Company cost-savings to management.
Conduct phone audits of randomly selected and/or focused Medicare Member Services or Commercial Customer Service inbound phone calls.
Produce scorecard for each call audited.