krg technology inc
Job Description
As a Quality Coordinator for Claims Processing, you will be responsible for reviewing all components of member submissions for paper claims. This Quality Coordinator role is essential to ensuring that all claims are properly processed to ensure the correct parties are billed for claims. You will review submitted member data in a workflow system (MedForce) against data in AS400 to ensure all claims data has been properly entered. The Quality Coordinator will also perform data mining to review the accuracy of member payments. Additionally, the Quality Coordinator will: Review and validate claims elements captured in the adjudication system against the claims forms and supporting documents submitted as detailed in the P&P’s and SOP Identify missing/incorrect claims elements and send claims back to Claims Processors for correction, with an emphasis on critical claims fields which result in non-conformance per regulatory guideline Validate corrections made by the processors to ensure 100% accuracy Validate claims payment contents – paid to, amount paid, and payment type Collaborate with the Paper Claims Processing Team and Supervisors to identify specific opportunities for improvement Raise and report errors to team supervisors. Also, identify trends and learning opportunities based on errors tracked Adhere to specified TAT as defined by the business Maintain a high level of self-learning to be up to date on the current P&P, SOP’s and regulatory guidelines and be available to conduct refresher and follow up training whenever required Required Qualifications 2+ years of experience in pharmacy/Medicare Part D claims processing or audit Quality auditing experience Proficiency in MS Word and MS Excel Preferred Qualifications Medicare Part D or related industry knowledge All your information will be kept confidential according to EEO guidelines.
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As a Quality Coordinator for Claims Processing, you will be responsible for reviewing all components of member submissions for paper claims. This Quality Coordinator role is essential to ensuring that all claims are properly processed to ensure the correct parties are billed for claims. You will review submitted member data in a workflow system (MedForce) against data in AS400 to ensure all claims data has been properly entered. The Quality Coordinator will also perform data mining to review the accuracy of member payments. Additionally, the Quality Coordinator will: Review and validate claims elements captured in the adjudication system against the claims forms and supporting documents submitted as detailed in the P&P’s and SOP Identify missing/incorrect claims elements and send claims back to Claims Processors for correction, with an emphasis on critical claims fields which result in non-conformance per regulatory guideline Validate corrections made by the processors to ensure 100% accuracy Validate claims payment contents – paid to, amount paid, and payment type Collaborate with the Paper Claims Processing Team and Supervisors to identify specific opportunities for improvement Raise and report errors to team supervisors. Also, identify trends and learning opportunities based on errors tracked Adhere to specified TAT as defined by the business Maintain a high level of self-learning to be up to date on the current P&P, SOP’s and regulatory guidelines and be available to conduct refresher and follow up training whenever required Required Qualifications 2+ years of experience in pharmacy/Medicare Part D claims processing or audit Quality auditing experience Proficiency in MS Word and MS Excel Preferred Qualifications Medicare Part D or related industry knowledge All your information will be kept confidential according to EEO guidelines.
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