Role Description
The QA Associate is responsible for conducting thorough and accurate reviews and audits of medical claims in accordance with established claims guidelines and policies.
Responsibilities
- Review claims or update existing claims by taking the appropriate and necessary actions as defined by guidelines
- Analyze claims to determine the appropriate course of action, approving or denying actions taken by agents as required
- Ensure that correct payment criteria have been applied for clearing pending claims, based on defined organizational policies and procedures
- Research claim edits to verify if the proper application of benefits has been made, including the use of established criteria and, when relevant, the application of physician contract pricing for entry-level claims processed by claims processors
- Review and confirm that provider inquiries related to claim adjudication have been properly addressed and resolved
- Understand and apply knowledge of medical coding (when applicable), as well as familiarity with various medical claims forms necessary to the claims process
- Handle high volume of repetitive claim audits efficiently
- Consistently improve productivity to meet or exceed minimum requirements while upholding quality standards
QUALIFICATIONS Education
- Bachelor’s degree in any field is required
- Credential or professional certification relevant to the current work is advantageous
Work Experience
- Previous experience in QA, specifically related to claims, is required
- Must have at least 2 years of experience in medical claims processing
- Experience with medical coding, including diagnosis coding and relevant terminology, is considered an advantage
Skillset
- Strong knowledge of US healthcare practices, including medical coding (ICD-10, CPT4, DRG, HCPCS), clinical documentation improvement, medical terminology, EDI, and HIPAA protocols is essential.
- Ability to multitask and follow documented claims processes with minimal supervision
- Excellent verbal and written communication skills for business purposes are necessary
- Strong proficiency in using Windows operating systems and Microsoft Office applications, with particular emphasis on Excel
- Keen attention to detail and the ability to make informed decisions based on presented information
- Good understanding of QA metrics and key performance indicators (KPIs)
Skills
Claims Management,CPT4,Medical Claims Processing,HIPAA,EDI,Medical Coding,ICD-10,Quality
