City/State

Overview

Work Shift

AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Claims QA Analyst in Miami and/or Gainesville, Florida. This is a hybrid position, 2 days in office and 3 days remote.

Scope of position:The Claims QA Analyst conducts audits of AvMed, Delegated Vendors, and Business Process Outsourcing (BPO) claims. The Claims QA Analyst conducts claims audits and works closely with the BPO to identify and correct any audit findings.

Essential Job Functions:

• Performs audits, analyzes system errors, identifies problems, and initiates corrective actions and preventative actions to ensure quality standards are in compliance with Federal and State regulations (CMS, DOI, AHCA, etc.) and AvMed policies and procedures. Coordinates with BPO and Delegated Vendors to finalize audit findings. Works with NTT to identify system errors and ensure that errors and claims impacted are corrected.
• Applies quantitative and qualitative analysis, maintains data integrity, and conducts quality improvement studies to support decision making, barrier analysis and implementation of interventions. Reviews any vendor initiatives established to ensure appropriate handling and compliance prior to development and implementation. Makes recommendation to Manager for approval.
• Conducts system testing, troubleshooting, implementation, and provides support to ensure business requirements are satisfied and configuration is accurate in contract and benefit configuration. Conducts random audit samples of manually and auto-adjudicated claims with an emphasis on claims payment and processing accuracy.
• Represent Manager in meetings.
• Provides with comprehensive claims analysis to management.
• Provides feedback on current procedures for efficiency and accuracy and assist supervisor in identifying additional training needs as result of their audit findings.
• Performs additional duties and responsibilities as assigned by management.

Minimum Requirements:

• Associates required
• Bachelor's in health sciences or similar concentration preferred
• 6-10 years of experience in a complex managed care environment with multiple products and entities, with an emphasis in claims, pricing and/or benefits. Previous audit or system configuration experience preferred
• An equivalent combination of education and experience may be considered

Preferred Requirements:

• Strong verbal and written communication skills
• Strong analytical and interpretative skills
• Excellent organizational skills
• Effective problem-solving skills and ability to handle simple and complex tasks
• Detail-oriented skills to adapt to various workflows, multiple tasks, deadlines and changing priorities
• Medical Coding including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-10) and Diagnosis-related Group (DRG) Codes
• HRP, MACESS, or Similar Software Systems
• Microsoft Office Suite (Word, Excel, Access)

Our Benefits:

As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to:

• Medical, Dental, and Vision Insurance
• Paid Annual Leave, Sick Leave
• Flexible Spending Accounts
• Retirement funds with matching contribution
• Supplemental insurance policies, including legal, Life Insurance and AD&D among others
• Work Perks program including discounted movie and theme park tickets among other great deals
• Opportunities for further advancement within our organization

Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Benefits - Sentara (sentaracareers.com)

Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, and growth!
Note: Sentara Healthcare offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.

Keywords: Talroo-Health Plan, #INDEED, Auditing, Claims, Configuration

Job Summary

Qualifications:

Skills

Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.

In support of our mission "to improve health every day," this is a tobacco-free environment.