Quality Assurance Specialist

Position Summary

The Quality Assurance Specialist is responsible for all claims audits and adjustments.

This role ensures the department's completeness, accuracy, and objectives while providing efficiency and effectiveness to Operations.

"Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job Description/Role."

Key Duties and Responsibilities


* Assist with the auditing and adjustments of all types of claims.


* Ensure the completion and submission of all required audit reports to management.


* Analyze and identify training needs based on audit results and system issues.


* Skilled in reviewing and adjusting various types of claims.


* Answer phone calls and greet walk-in customers in a friendly, courteous, and professional manner.


* Conduct backup tasks for various claims and customer service positions.


* Identify potential problems or trends in processes and suggest changes for management review.


* Identify potential issues and suggest possible solutions for improving processes.


* Must comply with the department's quality and error ratio guidelines for this job, as outlined in the Production and Error Ratio guidelines.


* Seeks opportunities to deliver the highest quality of service.

Actively listens and communicates effectively with participants, colleagues, clients, employers, and vendors.


* Excels in a team environment and requires minimal supervision.


* Provide assistance to participants, co-workers, clients, employers, and vendors in a friendly, courteous, and professional manner.


* Assist with specific projects as needed.


* Performs other duties as assigned.

Minimum Qualifications


* High School Diploma or GED.


* Strong knowledge of interpreting Plan Documents including Eligibility, Exclusions, and Limitations


* Minimum of 1 years of experience as a Claims Examiner, Customer Service Representative (CSR), or in specialized roles within the department.


* Possess a strong understanding of CPT, ICD-9, and HCPCS coding.


* Extensive knowledge of claims processes and customer service systems.


* Must be proficient in Microsoft Word, Excel, and basic database management.


* Skilled in company software, including Contribution Accounting System, Encounter Tracking, Claims System, and Electronic Reference.



*Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee of this job.

Duties, responsibilities and activities may change at any time with or without notice.

Working Conditions/Physical Effort


* Prolonged periods of sitting at a desk and working on a computer.


* Normal degree of physical effort in typical office environment with comfortable, constant temperatures and absence of objectionable elements.


* May be subject to interruptions.


* Must be able...