Quality Assurance Coordinator

Responsibilities

•    Prepare productivity, status, solicited and unsolicited analysis reports requiring the selection of data from records
•    Audit refunds from Department staff to providers to ensure request is valid, and appropriate monies are returned to providers
•    Review and issue refunds to providers due to Medicare/other insurances paying out of turn and “double-dipping” where funds have retrieved money and providers have paid, update notes in QNXT to reflect refunds made preventing penalties for paying out of turn from Medicare and other insurance
•    Review and determine that billing statement from outsource vendors to commission payments is correct, or specific charges should be removed.  Process refunds through the process of Oracle-working with Upper Management, MMP and the Finance Department t to ensure checks to Providers are generated and mailed
•    Research, troubleshoot and respond to online and written inquiries on overpayments activity from outsource vendors and Providers, communicating and collaborating with other functional areas of the Funds
•    Confirm existence of overpayments and verify amounts recoverable
•    Report audit findings of technical QCR’s to QA and Recovery Supervisors.  Provide Sr. Manager and Supervisors with feedback ensuring that staffs job duties are performed in an adequate manner and the Department’s standard and quality is maintained
•    Review checks received from Optum, updates notes and give final approval for deposit of checks received to the Finance Department
•    Review claim history from Optum cited overpayments to identify additional overpayments and forward it to the Recovery Unit for refund request or request reports to be run to internally identify and request refunds
•    Obtain proper documents for refunds returned to Providers including W-9and letters from providers requesting money
•    Perform backup functions for Recovery/Quality Assurance Supervisors, ensuring adequate coverage of critical functions (and Monthly Reports are generated timely)
•    Perform administrative support functions including Ordering supplies, filing, maintaining Sr. Manager’s calendar; facilitate managing of the office
•    Perform additional duties and special projects as assigned by Management.

Qualifications

• •    High Schol Diploma or GED required College Degree preferred; or the equivalent years of experience required
• •    Minimum two (2) years experience in the Health Care insurance or benefit environment required
• •    Perform administrative support functions including arranging disbursements to outsource vendors and providers
• •    Coordination of benefits (COB), claim processing, medical terminology, and systems (QNXT)
• •    Basic knowledge of Microsoft Word and Excel preferred
• •    Excellent problem solver with excellent analytical skills
• •    Able to work well under pressure, multi-task, establish priorities, meet deadlines, and follow through on assignments
• •    Excellent oral and written communication skills
• •    Strong organizational skills
• •    Ability to work independently and be a team player