Quality Control Analyst - Remote

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

JOB SUMMARY

The Quality Control Analyst is responsible for claims auditing and identifying examiner and system errors. This position also handles the auditing of claims special projects including risk pool, shared risk, Health Plan.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Creates clear and accurate audit findings and recommendation in written audit processing status codes that provides feedback to examiners used in examiner score card, identifies error trends and training opportunity.
• Retrospective auditing of paid claims on a quarterly basis. This includes flagging of overpaid claims for recovery.
• Identifies potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments
• Audits system configuration for new client implementation and provider or Health Plan contracts and amendments.
• Understands, interprets, and applies coding and reimbursement guideline; provider and Health Plan contracts for professional claims to ensure accuracy. Review of complex and high dollar claims to determine financial and risk accuracy and in-depth review of written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Software: Microsoft Office, EZ-Cap, McKesson Claim Check, Redbook, DRG Pricing Software
• Must be well versed in reading Health Plan DOFRs and understand all types of fee schedules, including risk pools.
• Excellent knowledge of CPT, RBRVS, DRG, HCPCS and ICD-9, ICD-10 coding and regulations.
• Ability to work in a virtual setting under minimal supervision
• Must display excellent interpersonal skills
• Strong knowledge and understanding of Managed Healthcare.
• Ability to create clear and concise audit reports and maintain productivity standards
• Excellent communication skills, written and verbal.
• Must be detail oriented and have the ability to work independently
• Ability to demonstrate initiative and discipline in time management and assignment completion

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

• 2-3 years of experience as Claims Adjuster
• Bachelor’s degree in Finance or Accounting or equivalent experience.
• 5 years of experience as a Quality Control Analyst.
• High school diploma or equivalent required

REQUIRED CERTIFICATIONS/LICENSURE

Include minimum certification required to perform the job.

• No certificate required

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Light physical effort (lift up to 10lbs). Mostly sedentary work. Regularly needs to be able to bend, stoop and reach to file.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Office Work Environment

TRAVEL

• Approximately 0% travel may be required

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.