Claims Quality & Support Officer - Enaya

Job description / Role

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

- Bachelor's Degree (Medical Degree or Nursing)
- Minimum 5 years' experience from Providers/TPA's in processing/adjusting claims (e.g. ICD-9/10, CPT, HCPC) or Minimum 3 years' experience auditing experience
- Demonstrated understanding of medical claims processes and procedures, and ability to recognize and interpret variances
- Legally permitted to work in the country of operations.
Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills

About the Company

With over 159,000 employees from 172 nationalities across more than 70 countries, we are one of the world's most trusted insurance and asset management companies. We offer a broad range of products and services in property/casualty insurance, life/health insurance, and asset management. We have our largest operational presence in Europe, and our parent company, Allianz SE, is headquartered in Munich, Germany. From jobs in Actuarial, Business and IT to Inhouse Consulting and Investment Management - your opportunities are endless!