Patient Privacy Compliance Specialist
Bluesight
Senior Quality Assurance Specialist, Member Claims
Collective Health
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $25 - $43 per hour
Job Level
Senior
Tech Stack
Node.js
About the role
- Lead comprehensive quality reviews of Member Claims Advocates' work, specifically targeting complex cases, high-dollar claims, and new hire performance to rigorously assess accuracy and decision-making.
- Manage and support responses to external audit requests, ensuring data integrity and compliance.
- Actively participate in Quality team meetings and calibration sessions, championing consistent scoring methodologies and a deep understanding of key metrics.
- Consistently maintain and strive to exceed an acceptable Claim Review Accuracy level.
- Contribute significantly to data-driven trend analysis, identifying root causes and actionable insights.
- Execute ad hoc claim reviews and perform in-depth deep-dive analyses to uncover systemic issues.
- Collaborate closely with Team Leads to develop and support training initiatives.
- Ensure strict adherence to all documented QA workflows and best practices.
Requirements
- 3+ years of experience as a medical claims examiner AND 2+ years dedicated to auditing and providing quality assurance feedback on medical insurance claims. Your combined background must demonstrate expertise in accurate benefit determination and a meticulous approach to ensuring claims accuracy and compliance.
- Advanced command of health insurance operations, including intricate details of deductibles, copayments, coinsurance, out-of-pocket maximums, in-network vs. out-of-network benefits, and various plan types (e.g., PPO, EPO, HDHP).
- Robust knowledge of medical coding systems (ICD-10, CPT, HCPCS, institutional revenue codes).
- Comprehensive understanding of regulatory guidelines and restrictions (HIPAA, ERISA, federal, state, and local mandates), coupled with the agility to adapt to evolving changes.
- Solid grasp of complex medical terms, conditions, procedures, and basic human anatomy/physiology.
- Exceptional attention to detail paired with a strong analytical mindset.
- Proficiency in reading and interpreting EDI formats (837i and 837p).
- Superior written and verbal communication skills to effectively collaborate, provide constructive feedback, offer clear guidance, and deliver precise instructions.
- Demonstrated knowledge and experience in software systems such as Microsoft or Google
- High degree of self-motivation, intellectual curiosity, and a strong sense of ownership.
- Exceptional research capabilities.
- Strong interpersonal relationship-building skills.
- Excellent organizational and time management skills.
- Effective listening skills and the ability to maintain focus amidst distractions.
- Absolute discretion when handling sensitive or private information.
- Preferred previous experience working for a Third Party Administrator that utilizes multiple repricing networks.
