Quality Control Reviewer III

Responsibilities: Cross train Processors and Quality Control Reviewers in the Hospital Claims Department Create advances from providers based on the findings of the Fraud & Abuse Department Review complex claim issues involving 1st, 2nd and 3rd level (IPRO) appeals Review and finalize claims according to Ceris findings Monitor claims processing system (QNXT) to ensure functionality of Hospital claims processing (i.e electronic, imaging, eligibility downloads from V3, pricing verification and pay-to-assignments) Review and handle ESI/ eviCore corrected claim reports Review and correspond with Aetna P.O.S on specific requests Ensure timely/accurate processing of hospital claims according to Claims Xten, Lab Management, Radiation Therapy, High-End Imaging, Medical Oncology and Specialty drug programs (i.e eviCore and CareContinuum); Summary Plan Description (SPD) guidelines, member benefits/eligibility parameters pre-authorization requirements; Fund policies and contracted/repricing rates Conduct system testing as it relates to QNXT upgrades, system enhancements and review performance of automated software Review Document Management System (DMS) inquiries/reconsiderations/medical records for accuracy, claims spreadsheets and determine action needed to rectify and resolve claims Process and evaluate facility claims manually or through DMS Respond in writing to provider inquiries/reconsiderations regarding claim adjustments/denials Resolve call tracking tickets and escalated e-mails in a timely manner Perform adjustments (related to inquiries, MedReview focused/revised DRGs Care Allies retrospective determinations); request credit refunds from provider and members; update member/claim memos regarding payment adjustments (overpayments and refunds) Request refunds for erroneous payments from providers and members Apply overpayments and refunds received and reported by the Claims Quality Assurance Department Perform additional duties and projects as assigned by management Qualifications High School Diploma or GED required, some College or Degree preferred Minimum (3) three years hospital claims processing required Strong knowledge of eligibility system, Coordination of Benefits (COB) guidelines and hospital claims processing required Intermediate knowledge of Microsoft Excel required; MS Word preferred Excellent communication skills both oral and written required; able to initiate correspondence and respond to inquiries in a clear and professional manner Ability to prioritize and work under pressure, with strict timelines and target dates Strong organizational and analytical skills with the ability to multi-task and follow up Good problem-solving skills with the ability to work independently and be a team player