Job Description

The Member Services Quality Auditor, reporting to the Claims Manager, is responsible for conducting Quality Assurance audits to monitor the quality and effectiveness of the claim adjudication process for claims processed manually and systematically. The Quality Auditor tracks and trends audit data to assess departmental and individual improvement opportunities and to assure regulatory compliance and accreditation standards are met. The Member Services Quality Auditor provides monthly reports to Health Plan Management.

• Performs quality reviews on pre and post-payment claims processed manually and auto-adjudicated claims to ensure internal department standards and regulatory requirements are met.
• Audits high dollar claims while maintaining acceptable levels of claims inventory and age.
• Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, system configuration and pricing, provider information, pre-authorization, ensuring claim examiners follow processing guidelines to address action codes and ensure correct overrides and correct explanations are applied to the claim.
• Analyze reported errors for trends.
• Works with claims trainer to identify, document, and propose solutions for areas of concern requiring further one-on-one or group training.
• Support the claims department by reviewing procedural documentation on claims processing as they relate to QA reviews. Provide recommendations based on findings.
• Provide the Director of Claims, Claims Manager, and Claims Supervisors with timely, detailed monthly reports that outline departmental and individual statistical results.
• Collaborate with and maintain open communication with all departments within CHRISTUS Health to ensure effective and efficient workflow and facilitate the completion of tasks/goals.
• Follow the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
• Performs other duties as assigned by management to support claims functions, which are focused on achieving both departmental and organizational objectives.

• Bachelor’s degree preferred or equivalent job-related experience.
• Thorough knowledge of medical terminology, CPT, HCPCS, ICD-10, Revenue Codes, CMS-1500 and CMS-1450 claim forms
• Excellent written, verbal and interpersonal communication skills required.
• Spreadsheet and database skills required.
• Proficient in Microsoft Office
• Ability to organize and prioritize work to meet deadlines.
• Good judgment, initiative, and problem-solving abilities
• Minimum of at least five (5) years’ experience in medical claims processing and adjustments at a healthcare organization.
• Medical claims quality auditing experience is highly desirable.
• Experience with managed care, Medicare, Health Exchange, and Tricare.

Full Time

131511

Member Services Quality Auditor II

CHRISTUS System Office

General Operations

CHRISTUS Corp Health Plan 919 and 909 Buildings

FULL TIME