[Remote] Claims Quality Assurance Analyst (Remote)

Note: The job is a remote job and is open to candidates in USA. Tango is hiring a Claims Quality Assurance Analyst to ensure the accuracy and compliance of claims processing through audits, analysis, and issue resolution. The role also supports vendor compliance, provider audits, records requests, and improvements to internal audit processes.

Responsibilities

• Validate claims data against information from claims processing systems to ensure that data is accurate (for both auto adjudicated claims as well as manually processed claims)
• Analyze claims data against applicable policies and regulations to identify potential issues (e.g., member benefits, billing anomalies, payment accuracy, claims processing system issues)
• Review history of related claims to pull in and understand additional claims-related information
• Calculate dollar amount of financial claims errors/defects
• Develop and deliver fact-based audit determinations in an objective, non-confrontational manner
• Escalate issues identified during the audit cycle or rebuttal process to applicable stakeholders, as appropriate (e.g., Operations Team, Quality Team)
• Ensure compliance with applicable audit and rebuttal timelines (rebuttal timelines/form completion, workflows, turnaround time)
• Achieve production quality goals/metrics (e.g., audits per hour, audit accuracy, first-pass accuracy, rebuttal accuracy)
• Provide supporting documentation for audit findings
• Identify/communicate escalated errors/defects and ensure proper resolution, as needed (e.g., rebuttals, appeals)
• Communicate audit findings to applicable stakeholders (e.g., error descriptions, rebuttal information)
• Identify, communicate, and implement opportunities for improving internal audit/rebuttal processes within the Quality team
• Identify, interpret, and utilize applicable claims and audit policies and procedures
• Demonstrate understanding of how various factors may impact claims accuracy (e.g., system edits, keying vendor discrepancies, system logic)
• Demonstrate knowledge of the healthcare industry (e.g., billing practices, terminology, legal/regulatory requirements, coding standards)
• Identify and interpret applicable plan benefit information (e.g., Contracts)
• Maintain Claim Policies/Procedures/Job Aids to stay within Compliance annually
• Oversee Annual Vendor Compliance Process
• Support Adhoc Provider Audits Quarterly
• Supports Records requests/subpoenas in coordination with Compliance
• Oversees quality and findings in internal and external audits, all vendors and staff accuracy
• Perform other duties as assigned within the scope of responsibilities and requirements of the job
• Performs the essential functions of this job with or without reasonable accommodation

Skills

• 5 ~ 7 years of direct experience minimum
• Advanced level of skills and knowledge of technical system operations
• Solid understanding of enrollment and eligibility as well as claims paying for all lines of business
• Professional level training that provides a general understanding of:
• The administration of all contractual obligations
• Audit and billing procedures
• Policies and procedures
• How the processing of accounts receivable and eligibility requirements impacts claims processing
• Vendor data feeds and discrepancy process
• Administrative and regulatory requirements
• Technical workflow processes
• Functional requirements of the system
• Solution design documents
• 4 ~ 6 years' work experience that provides a working knowledge of:
• Claims billing and delinquency procedures
• Accounts receivable process
• System testing and enhancement process
• Web portal data support
• Advanced level Microsoft Office skills (PowerPoint, Word, Outlook)
• Advanced level Microsoft Excel skills
• Interpersonal, communication (written and verbal) and presentation skills
• Analytical, research, problem solving, and decision-making skills
• Ability to monitor team goals
• Ability to lead and coach team members

Benefits

• Remote work

Company Overview

Company H1B Sponsorship