Claims Quality Auditing Specialist IV

Investigates claims reviews/appeals by performing audits to validate conformance with policies and payment methodologies and analyzing data to identify problems. Evaluates audit processes by developing/testing criteria to ensure processes are compliant, conducting assessments to ensure data and quality standards are maintained, and providing feedback. Documents claims outcomes by determining coverage eligibility, and preparing reports of findings, and offering thoughts on resolving the issue. Facilitates the resolution of payment discrepancies by using strategies, responding to findings, addressing issues, and coordinating /audits. Contributes to compliance processes by developing/reviewing training and procedure requirements, developing instructional material, assigning work, and participating in trainings. Facilitates efforts to optimize system improvements by identifying/investigating issues, researching and providing feedback on process efficiencies, generating reports/reporting systems, and suggesting policy changes to improve processes.

• Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.


• Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.


• Documents the resolution and reporting of claims outcomes by: independently verifying determination of claims payment accuracy following written guidance; documenting audit findings, claims issues, and trends, meeting all documentation requirements for audit outcomes, pricing calculations, claims information, and root cause; and presenting findings/trends to internal and external teams, departments, and managers.


• Evaluates audit processes by: independently utilizing audit criteria used to ensure common audits are compliant with contract terms, policies, procedures, practices, internal controls, and state and federal laws; and supporting team efforts to conduct claims quality assessments, to ensure quality standards are maintained across the audit process, which could include billing and data integrity, and providing feedback to internal and/or external teams.


• Investigates claims reviews and appeals by: performing specialized audits and analyses of medical claims payment and invoice data (e.g., claim adjustments, referrals, refunds, provider disputes) to validate conformance with specified coverage policies and payment methodologies using independent judgment; and analyzing data to identify problems of a moderate scope.


• Contributes to efforts to monitor and optimize system improvements by: identifying issues and working with supervisors and other team members to investigate department-wide issues impacting metrics related to pricing, billing, cost containment, and benefit compliance; identifying technology and operational process efficiencies and providing feedback on solutions to improve workforce management and claims processing accuracy; and making changes to policy and implementing strategies to improve internal processes and controls and ensure that assigned processes meet regulatory guidelines as specified by all relevant regulatory agencies.


• Contributes to compliance working processes by: using advanced knowledge of business practices to work with management and develop training requirements for internal claims team in response to changes in policies, procedures, or findings and trends in claims processing; reviewing and/or participating in the development of instructional material for team members and department stakeholders with limited direction; and participating in approved trainings on topics related to claims systems, processes, data, and policies as instructed.