[Hiring] Quality Assurance Specialist @GEHA Health

Role Description

The Quality Assurance Specialist audits claims coding, customer service calls or electronic files for accuracy, benefit payment, contract interpretation, and compliance with policies and procedures.

• Updates and completes daily, monthly, and annual reports.
• Prepares responses to correspondence and manages complex provider issues and calls.
• Answers questions from PDM staff and other departments regarding provider updates and issues.
• Makes recommendations to improve quality, workflow processes, policies, and procedures.

Credentialing:

• Chairperson
• SAL Audit
• VP Files (CVO Initial & CVO Re-Creds)
• WAP Audit
• OGM Invalid License
• IH Initial & Re-Creds
• Cred Verification
• MS Review Audit
• Contract Audit

Provider Verification:

• Provider Relations
• Call Audits
• Service Issue Audit
• Case Audit
• Audit Errors

• Assists with department training.
• Contributes independently and collaboratively across departments and cross-functional projects.
• Analyzes audit reports and rebuttals to identify trends and recommend determination of outcome.
• Reviews and makes suggestions for changes/updates to training materials and existing desk-level procedures and policies.

Qualifications

• Requires an associate's degree. Will consider additional experience in lieu of degree.
• Requires 4 years of related experience.
• Requires effective written and verbal communication skills to answer questions from staff and providers.
• Requires proficiency with MS Word and MS Excel.
• Must have thorough knowledge of Provider Data Management policy and procedures.

Requirements

• Experience as an Associate Quality Assurance Specialist within PDM preferred.
• Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
• A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
• Latency (ping) response time lower than 80 ms.
• Hotspots, satellite and wireless internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Benefits

• Competitive pay/salary ranges.
• Incentive plan.
• Health/Vision/Dental benefits effective day one.
• 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution.
• Robust employee well-being program.
• Paid Time Off.
• Personal Community Enrichment Time.
• Company-provided Basic Life and AD&D.
• Company-provided Short-Term & Long-Term Disability.
• Tuition Assistance Program.