Quality Control Reviewer III

Responsibilities

• Cross train Processors and Quality Control Reviewers in the Hospital Claims Department
• Create advances from providers based on the findings of the Fraud & Abuse Department
• Review complex claim issues involving 1st, 2nd and 3rd level (IPRO) appeals
• Review and finalize claims according to Ceris findings
• Monitor claims processing system (QNXT) to ensure functionality of Hospital claims processing (i.e electronic, imaging, eligibility downloads from V3, pricing verification and pay-to-assignments)
• Review and handle ESI/ eviCore corrected claim reports
• Review and correspond with Aetna P.O.S on specific requests
• Ensure timely/accurate processing of hospital claims according to Claims Xten, Lab Management, Radiation Therapy, High-End Imaging, Medical Oncology and Specialty drug programs (i.e eviCore and CareContinuum); Summary Plan Description (SPD) guidelines, member benefits/eligibility parameters pre-authorization requirements; Fund policies and contracted/repricing rates
• Conduct system testing as it relates to QNXT upgrades, system enhancements and review performance of automated software
• Review Document Management System (DMS) inquiries/reconsiderations/medical records for accuracy, claims spreadsheets and determine action needed to rectify and resolve claims
• Process and evaluate facility claims manually or through DMS
• Respond in writing to provider inquiries/reconsiderations regarding claim adjustments/denials
• Resolve call tracking tickets and escalated e-mails in a timely manner
• Perform adjustments (related to inquiries, MedReview focused/revised DRGs Care Allies retrospective determinations); request credit refunds from provider and members; update member/claim memos regarding payment adjustments (overpayments and refunds)
• Request refunds for erroneous payments from providers and members
• Apply overpayments and refunds received and reported by the Claims Quality Assurance Department
• Perform additional duties and projects as assigned by management

Qualifications

• High School Diploma or GED required, some College or Degree preferred
• Minimum (3) three years hospital claims processing required
• Strong knowledge of eligibility system, Coordination of Benefits (COB) guidelines and hospital claims processing required
• Intermediate knowledge of Microsoft Excel required; MS Word preferred
• Excellent communication skills both oral and written required; able to initiate correspondence and respond to inquiries in a clear and professional manner
• Ability to prioritize and work under pressure, with strict timelines and target dates
• Strong organizational and analytical skills with the ability to multi-task and follow up
• Good problem-solving skills with the ability to work independently and be a team player