Claims Quality And Support Associate
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Key skills for this role
About the Role
TALENTMATE is seeking a Claims Quality And Support Associate to review and inspect operational claim processes, ensure quality standards, and create audit findings. The role requires analyzing medical records, coding, and verifying claims documents.
Key Skills for This Role
Responsibilities
- Responsible for activities concerned with review and inspection to apply quality standards for operational claim processes and adjudication
- Creates clear and accurate audit findings and recommendation in written audit processing status codes
- Understands, interprets, and applies coding and reimbursement guideline; provider and Health Plan contracts for professional claims
- Audit, assess, and monitor providers and payers, including medical records, and independently codes and abstracts
- Analyze inpatient and outpatient medical records using ICD 9/ICD 10, CPT, HCPCS, UB and other codes
- Verify and validate claims documents to rule out documentation/coding errors or fraud
- Prepare concise documentation and audit reports, including recommendations for improvements
- Special focus on regulatory audit requirements, reports and findings
- Issue monthly summary of findings with recommendations
Requirements
- Bachelor’s degree in any Medical field, Paramedical, Finance, Business Administration, Insurance, or a related field preferred
- 3 5 years’ experience in a customer focused environment, ideally in clinical, paramedical roles or TPA or insurance roles
- Demonstrated understanding of medical claims processes and procedures
- Proficiency in MS Office and general internet navigation and research skills
- Must be detail oriented and have the ability to work independently
- Legally permitted to work in the country of operations
Full Job Posting
Job Description
- Responsible for activities concerned with review and inspection to apply quality standards for operational claim processes and adjudication.
What You Do
- 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.
- Understands, interprets, and applies coding and reimbursement guideline; provider and Health Plan contracts for professional claims to ensure accuracy.
- 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
- 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.
- Prepare concise documentation and audit reports, including recommendations to claims management for improvements with corrective action plans.
- 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.
- Other Ad hoc duties as required.
- AI READINESS Work effectively in an environment shaped by artificial intelligence (AI), machine learning, data, analytics and cloud based tools, using insights responsibly with our standards of data governance, security and ethical use.
What You Bring
- Bachelor’s degree in any Medical field, Paramedical, Finance, Business Administration, Insurance, or a related field preferred.
- 3 5 years’ experience in a customer focused environment, ideally in clinical, paramedical roles or TPA or insurance roles.
- Demonstrated understanding of medical claims processes and procedures, and ability to recognize and interpret variances.
- Proficiency in MS Office and general internet navigation and research skills.
- Must be detail oriented and have the ability to work independently.
- Legally permitted to work in the country of operations.
- Hybrid working option available as per business requirements.
How We Hire
- Allianz Partners does not accept unsolicited CV’s or approaches from agencies. We only work with partners on our approved supplier list, under contract. Any unsolicited submission will not be considered.
What We Offer
- Allianz Partners is a world leader in B2B2C insurance and assistance, offering global solutions that span international health and life, travel insurance, automotive and assistance.
- At Allianz Partners, Artificial Intelligence (AI) is transforming service delivery and innovation.
- Allianz Group is one of the most trusted insurance and asset management companies in the world.
- At Allianz, we stand for unity: we believe that a united world is a more prosperous world, and we are dedicated to consistently advocating for equal opportunities for all.
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