Job description
LE0006 MSO of Puerto Rico, LLC
It's fun to work in a company where people truly BELIEVE in what they're doing!
We're committed to bringing passion and customer focus to the business.
POSITION DESCRIPTION:
Responsible for Quality Review of claim processed or configuration changes by Claim Analysts, Claim Adjuster, Business Configuration Unit Analyst, Provider Network Operator Analyst and any other areas identified in the claims department, on a daily basis in order to obtain data for monthly quality results and comply with the internal Instruction, CMS and Medicaid regulations.
RESPONSIBILITIES:
Responsible to assure quality results of process in each claims department area (Claim Analysts, Claim Adjuster, Business Configuration Unit Analyst, Provider Network Operator Analyst and any other area). to be reviewed the next working day when the claim or configuration was processed. Main responsibility includes the daily Quality Review of processed (obtained by production reports) per day, Claim Analysts, Claim Adjuster, Business Configuration Unit Analyst, Provider Network Operator Analyst, and any other area identified in the claims department according to the Claims Policies Maintain updated with all processing guidelines, E-mails, new processing instructions, and Wiki Claims to apply and identify quality errors within the monthly Quality Review. Maintain the Quality Production report updated on a daily basis on the public drive Dakota. Complete Quality Review Audits for each month as established on the Due Dates schedule between 2nd and 3rd day on the next month. Maintain open communication with other areas for claim processing changes and update’s not limited to fee schedules, Medicare and Medicaid policies, and claim editing updates impacting claim payments. Perform monthly internal CMS audits of pay and deny claims, on a timely basis (according to schedule established by Quality Supervisor). Responsible to communicate the Quality Supervisor any error trend identified to the analyst based in a targeted or random audit. Review and quantify errors by error codes to identify top errors and areas of opportunity to educate processing personnel on an individual or group basis. Participate in new initiatives to assure quality in the processes. Comply with monthly precision standard. Special Projects will be assigned, when necessary.
EDUCATION AND EXPERIENCE:
Bachelor's degree (B. A.) from four-year college or university; or three to four years related experience and/or training; or equivalent combination of education and experience.
LANGUAGE SKILLS:
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from managers, clients, customers, and the general public.
MATHEMATICAL SKILLS:
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
REASONING ABILITY:
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
GENERAL SKILLS:
- Bilingual (English – Spanish)
- Manage and solve problems
- Time management skills; establishing priorities and accomplishing tasks in an accurate and timely basis.
- Computer literate.
- Strong healthcare claims processing expertise and medical terminology knowledge.
- Oral and written communication skills.
INTERPERSONAL SKILLS:
The responsibilities of this position require continuous interaction with supervisors in order to solve problems and offer feedback.
PHYSICAL AND MENTAL DEMANDS:
While working the employee is walking, standing, talking and listening most of the time. The job also requires being able to reach objects with arms and hands.
ENVIRONMENTAL AND WORKING CONDITIONS:
Normal busy office environment. Moderate noise (examples: business office with computers and printers, light traffic)
If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
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