JOB SUMMARY The Claims Quality Review Auditor is responsible for auditing various claims to ensure quality and accuracy to related benefit payments, contract interpretation, and compliance with policies and procedures and regulatory guidelines. Makes recommendations to improve quality, workflow processes, policies and procedures.
ESSENTIAL FUNCTIONS OF THE ROLE
Tracks and trends audits in an effort to identify root cause errors to providers; provides feedback.
Ensures that the department's procedural manuals consistently support adherence to regulatory guidelines, internal policies and procedures related to claims processing and departmental accuracy standards related to claims payment.
Develops practical recommendations to management to improve control processes to safeguard assets and improve the efficiency and effectiveness of operations.
Works to effectively and professionally resolve any discrepancies in claims payments with other departments.
Audits claims data to determine claim adjudicator and system accuracy, and completes statistical reports on findings to record audit activity and recommendations.
Communicates significant audit findings to management.
Prepares action plans and submits documentation to management regarding the results of follow-up reviews.
Reports areas of non-compliance to management.
Prepares and submits detailed audit reports to management to aid in the training/education of staff.
KEY SUCCESS FACTORS
An Associates Degree or equivalent formal training program preferred.
Must have experience with Microsoft Word, Excel, Amisys and Macess.
Excellent written/verbal communication and interpersonal skills required.
Must possess the ability to maintain strict confidentiality at all times.
Exercises good judgment, attention to detail, integrity, dependability, objectivity, and strong analytical skills.
Demonstrates a working knowledge of good internal controls.
Demonstrates the ability to design action plans and perform follow-up reviews in a timely manner.
BENEFITS - Our competitive benefits package includes the following
Immediate eligibility for health and welfare benefits
401(k) savings plan with dollar-for-dollar match up to 5%
PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!