Claims Quality & Support Officer - Enaya

What we do

The Claims Quality & Support Officer responsible for activities concerned with review and inspection to apply quality standards for operational claim processes and adjudication

What you do

- Prepare concise documentation and audit reports, including recommendations to claims management for improvements with corrective action plans;
- Audit, assess, and monitor providers and payers, to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral healthcare, laboratory, etc. medical records, and independently codes, and abstracts.
- Analyze inpatient and outpatient medical records using most current International Classification of Diseases (ICD-9/ICD-10), Current Procedural Terminology (CPT), Health Care Common Procedure Coding System (HCPCS), Universal Billing (UB) and other codes, regulatory and contractual requirements, and generally accepted coding practices.
- Verify and validate claims documents received through multiple channels to rule out possibility of documentation / coding errors or other inconsistencies that may occur in case of suspected fraud and abuse cases.
- Special focus and priority will be given to regulatory audit requirements, reports and findings.
- A summary of findings will be issued on monthly basis through a report, including recommendations on changes to be made, aligned with the Claims Quality Manager
- Any other task required by the manager, within the scope of Audit and Claims Support

Requirements: