Claims Quality & Support Associate
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Key skills for this role
About the Role
Nextcare seeks a Claims Quality & Support Associate to review and inspect operational claim processes, apply quality standards, and audit medical records.
Key Skills for This Role
Responsibilities
- Review and inspect operational claim processes and adjudication to apply quality standards
- Create clear and accurate audit findings and recommendations for examiner score cards
- Understand, interpret, and apply coding and reimbursement guidelines, provider and Health Plan contracts
- Audit, assess, and monitor providers and payers, including medical records and coding
- 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 with recommendations for improvements
- Issue monthly summary of findings with recommendations to Claims Quality Manager
Requirements
- Bachelor's degree in Medical field, Paramedical, Finance, Business Administration, Insurance, or related field preferred
- 3 5 years experience in customer focused environment, ideally in clinical, paramedical, TPA or insurance roles
- Demonstrated understanding of medical claims processes and procedures
- Proficiency in MS Office and general internet navigation and research skills
- Detail oriented and ability to work independently
- Legally permitted to work in the country of operations
Full Job Posting
What You Do
- Responsible for 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 to claims management.
- Special focus on regulatory audit requirements, reports and findings.
- Issue monthly summary of findings with recommendations aligned with Claims Quality Manager.
- Other Ad hoc duties as required.
- Work effectively in an environment shaped by AI, machine learning, data, analytics and cloud based tools.
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.
- 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.
About Allianz Partners
- Allianz Partners is a world leader in B2B2C insurance and assistance.
- Offers global solutions spanning international health and life, travel insurance, automotive and assistance.
- Products available through four commercial brands: Allianz Assistance, Allianz Automotive, Allianz Travel and Allianz Care.
How We Hire
- Allianz Partners does not accept unsolicited CVs or approaches from agencies.
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