Job Description

Quality Assurance Specialist I

Job Category: Claims

Location: Birmingham, AL

Work Schedule: Hybrid schedule with regular onsite presence at the VIVA HEALTH corporate office and some work-from-home opportunities. Must be available to work during the core hours of operation, 8am to 5pm Monday through Friday, and overtime as required.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

Benefits

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Healthcare Reimbursement Account
• Paid Parental Leave
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Employee Assistance Program

Job Description

The Quality Assurance (QA) Specialist is responsible for the overall development and implementation of quality assurance in an effort to provide customers with superior service. This role is responsible for auditing and reporting analysis of Claims and Entry staff, Commercial Customer Service phone queue calls, Medicare Member Services phone queue calls, System Configuration, and Provider/Fee Configuration.

Key Responsibilities

• Review Claims Entry and Adjudication staff for accuracy based on applicable plan coverage documentation in accordance with departmental policies and procedures, company compliance plans, and all regulatory guidelines.
• Document and distribute error findings to management for review. Provide training and education to Claims Entry and Adjudication staff on claims payment issues to ensure claims are adjudicated in an effective and efficient manner.
• Identify and report benefit configuration issues; communicate with internal departments to resolve problems that affect claim payment.
• Investigate claim submissions for coding inaccuracies, review high dollar remittances for payment and benefit configuration accuracy. Report overall Company cost-savings to management.
• Conduct phone audits of randomly selected and/or focused Medicare Member Services or Commercial Customer Service inbound phone calls. Produce scorecard for each call audited.

Required:

• High School Diploma or GED
• 2 years working with all components of claims processing, Medicare enrollment, and/or customer service
• Knowledge of ICD9, CPT, HCPCS, HCFA, Uniform Billing codes, and Co-ordination of Benefits (COB)
• Proficient in medical terminology
• Demonstrate excellent customer service skills through written and verbal communication
• Ability to prioritize and multitask while maintaining organization and attention to detail
• Ability to work in a team environment, remaining flexible to ideas, routines and schedules, recognizing responsibilities, and actively participating with others to accomplish assignments and achieve desired goals

Preferred:

• PowerSTEPP (TXEN) experience
• Quality Assurance experience
• Coding experience

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

Job Tags

Similar Jobs