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    Quality Control Lead Analyst - Taguig, Pilipinas - Tenet Healthcare

    Tenet Healthcare
    Tenet Healthcare Taguig, Pilipinas

    1 linggo ang nakalipas

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    Job Description:

    The role of the Lead Quality Control Analyst includes auditing medical claims, monitor check run and compliance, handling quality control related escalations.

    Duties and responsibilities:

    • Understands, interprets and applies coding and reimbursement guideline; provider and Health Plan contracts for professional and institutional claims to ensure accuracy. Review of complex and high dollar claims to determine financial and risk accuracy and in depth review of written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers for all types of claims.
    • Identifies potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments
    • Creates clear and accurate audit findings and recommendation in written audit processing status codes that provides feedback to examiners used in examiner score card, identifies error trends and training opportunity
    • Ensure audit timeline is adhered to and deliver high quality service to clients
    • Audits system configuration for new client implementation and provider or Health Plan contracts and amendments.
    • Monitor the check run process by running the nearing non-compliance report and ensuring these claims are paid timely. Manually moves claims into the check run process as required. This will include special projects, Health Plan demand letters, Fast tracks and claim nearing non-compliance.
    • Retrospective auditing of paid claims on a quarterly basis. This includes flagging of overpaid claims for recovery.

    Required Educational Attainment and Work Experience:

    • Bachelor's degree or equivalent work experience required
    • High school diploma or equivalent required
    • 5 years' experience processing managed health care claims preferred.
    • 2-3 years of experience as Claims Adjuster

    Working Conditions:

    • Amenable to work in BGC, Taguig
    • Willing to work in a nightshift schedule.

    Company Benefits:

    • Competitive Salary
    • HMO on day 1 plus 1 dependent; Additional 2 HMO dependents upon regularization
    • Group life insurance
    • PTO Credits
    • Annual Appraisal
    • Annual Performance Bonus
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