Claims QI Analyst

Job Summary

The Claims Quality Assurance (QA) Analyst will conduct routine oversight monitoring and auditing of all business functions within CalOptima, to ensure compliance with federal, state, regulatory, and internal guidelines. The incumbent will ensure that the Claims department is adhering to regulatory and internal guidelines in conjunction with CalOptima policies and procedures, as they apply to claims processing.

Position Responsibilities:

• Conducts routine audit of claims processed to ensure continued adherence to CalOptima policies and procedures and compliance to regulatory requirements.
  
• Conducts monthly health network audits.
  
• Manages and plans multiple concurrent audits and related projects, makes decisions around objective and scope, and ensures effective and efficient audit execution.
  
• Informs the department of any changes to regulatory requirements.
  
• Assists in the facilitation of mock audits of departmental functions using designated audit tools and develops Corrective Action Plans (CAPs) to address any deficiencies.
  
• Performs audit validation of monthly claims and Provider Dispute Resolution (PDR) universe submissions.
  
• Serves as a knowledge expert for assigned functional areas.
  
• Reports and tracks audit findings, identifies areas of concerns, and validation of remediation efforts, which includes but is not limited to identifying potential solutions (immediate and long-term) controls.
  
• Provides written and oral summaries of audit analyses as needed.
  
• Interprets and applies guidance from industry standards and audit protocols.
  
• Functions as a liaison with other areas and business units.
  
• Other projects and duties as assigned.
  

Possesses the Ability to:

• Influence others using a positive approach as well as encouraging and utilizing new suggestions and ideas.
  
• Communicate clearly and concisely, both verbally and in writing.
  
• Establish and maintain effective working relationships with CalOptima leadership and staff.
  
• Handle multiple tasks and meet deadlines.
  
• Identify issues and problems, develop solutions, and prepare recommendations.
  
• Utilize computer and appropriate software (e.g., Microsoft Office, Excel, Outlook, PowerPoint, Word) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
  

Requirements

Experience & Education:

• Bachelor s degree in Healthcare Administration or relevant field, or the equivalent combination of education and/or related experience required.
  
• 2 years of medical health claims processing experience required.
  
• 2 years audit experience in Audit & Oversight, Claims Administration, Customer Service, or applicable area required.
  

Knowledge of:

• Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi-Cal Fee schedule, All Patient Defined Diagnosis Related Group (AP-DRG), Ambulatory Payment Classification (APC), Healthcare Common Procedure Coding Systems (HCPCS) codes.
  
• International Classification of Diseases (ICD)-10, Current Procedure Terminology (CPT), and Revenue Codes.
  
• Managed Care compliance for Medi-Cal and Medicare.
  
• Center for Medicare & Medicaid Services (CMS) and Medi-Cal/Department of Healthcare Services (DHCS) claims processing regulations.
  
• Fundamental principles of writing and grammar, including proper report and correspondence format, correct spelling, and proper work usage, grammar, punctuation, and sentence structure.
  

Benefits

At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:

Competitive pay & weekly paychecks

Health, dental, vision, and life insurance

401(k) savings plan

Awards and recognition programs

Benefit eligibility is dependent on employment status.

Sunshine Enterprise USA is an Equal Opportunity Employer Minorities, Females, Veterans and Disabled Persons