MetroPlusHealth
Join to apply for the
Claims Quality Analyst
role at
MetroPlusHealth 1 day ago Be among the first 25 applicants Join to apply for the
Claims Quality Analyst
role at
MetroPlusHealth Get AI-powered advice on this job and more exclusive features. This range is provided by MetroPlusHealth. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more. Base pay range
$55,000.00/yr - $65,000.00/yr Empower. Unite. Care.
MetroPlusHealth
is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.
About NYC Health + Hospitals
MetroPlus Health
provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus Health 's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus Health
has been committed to building strong relationships with its members and providers.
Position Overview
Claims Quality Auditor is responsible for reviewing claims to determine if payments have been made correctly. This position analyzes data used in settling claims to determine the validity of payment of claims and reports overpayments, underpayments and other irregularities based upon benefit configuration, compliance with provider contract agreements, and Federal, State and Plan’s established guidelines and/or policies and procedures. The incumbent will research, review, and suggest process improvements, training opportunities and is a resource of information to all staff. The incumbent will also perform special projects.
Work Shifts
9:00 A.M – 5:00 P.M
Duties & Responsibilities
Audit daily processed claims through random selection based on set criteria. Document, track, and trend findings per organizational guidelines Based upon trends, determine ongoing Claims Examiner training needs, and assist in the development of training curriculum. Conduct in-depth research of contract issues, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends. Recommend actions/resolutions. Work with other organizational departments to develop corrective action plans to improve accuracy of the claims adjudication processes and assure compliance with organizational requirements and applicable regulations Assist in the development of Claims policies and procedures Provide backup for other trainers within the department Assist in training of new departmental staffs Assist with the research and resolution of audit appeals Asist with external/internal regulatory audits Identify policies or common errors requiring retraining sessions. Participate in quality projects as required. Collect, analyze data, identify trends, write reports (i.e., the monthly and quarterly reports) and present findings to the appropriate claims service management personnel. Other duties as assigned by senior management
Minimum Qualifications
Associate degree required; Bachelor’s degree preferred Minimum of 4 years of experience performing claims quality audits in a managed care setting Expertise in both professional and institutional claims coding, and coding rules required. Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and standard industry reimbursement methodologies required. Strong knowledge of CMS Medicare and NYS regulations required. Experience in training development and presentation preferred Must have excellent interpersonal, verbal, and written communication skills
Professional Competencies
Strong organizational, analytical, and oral/written communication skills required. Proficiency in PC application skills, e.g., excel, word, PowerPoint, etc., Must be able to follow direction and perform independently according to departmental Integrity and Trust
Benefits
NYC Health and Hospitals offers a competitive benefits package that includes:
Comprehensive Health Benefits for employees hired to work 20+ hrs. per week Retirement Savings and Pension Plans Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts Loan Forgiveness Programs for eligible employees College tuition discounts and professional development opportunities College Savings Program Union Benefits for eligible titles Multiple employee discounts programs Commuter Benefits Programs
#MHP50
Seniority level
Seniority level Mid-Senior level Employment type
Employment type Full-time Job function
Job function Quality Assurance Industries Hospitals and Health Care Referrals increase your chances of interviewing at MetroPlusHealth by 2x Sign in to set job alerts for “Quality Analyst” roles.
Jersey City, NJ $54,500.00-$100,300.00 1 day ago Edison, NJ $70,000.00-$105,000.00 2 weeks ago Audit (Business and Finance) | Analyst | New York
Bronx, NY $63,999.94-$79,999.92 3 weeks ago New York, NY $55,000.00-$65,000.00 4 days ago Internal Audit-New York-Analyst-Enterprise Risk Management - Business Liaison
SENIOR QUALITY ASSURANCE AUTOMATION ENGINEER
New York City Metropolitan Area 12 hours ago Technology Analyst 1 (Quality Assurance) - Project Assistant
New York, NY $86,681.00-$109,650.00 1 week ago Technology Analyst 1 (Quality Assurance) - Project Assistant
New York, NY $86,681.00-$109,650.00 1 week ago Analyst, Sports Business Development & Innovation
New York, NY $87,682.00-$120,560.00 1 week ago Business Automation Integration Analyst - Advertising Ops
New York, NY $83,000.00-$97,000.00 1 week ago Jersey City, NJ $82,493.00-$107,241.00 3 weeks ago New York, NY $88,000.00-$125,000.00 3 weeks ago Technology Analyst 2 (Quality Assurance) - Project Assistant
New York, NY $96,336.00-$121,413.00 1 week ago Senior Quality Engineer (Wayne, NJ) Defined Term
Wayne, NJ $100,000.00-$115,000.00 1 week ago Manufacturing Planner / Inventory Analyst
East Rutherford, NJ $66,600.00-$104,610.00 1 week ago Technology Analyst 2 (Quality Assurance) - Project Assistant
New York, NY $96,336.00-$121,413.00 1 week ago Global Supply Chain Analyst - Regulatory & Quality
Allendale, NJ $56,000.00-$84,000.00 2 weeks ago New York City Metropolitan Area 2 days ago New York, NY $77,000.00-$87,000.00 1 week ago New York, NY $140,000.00-$170,000.00 2 weeks ago New York, NY $94,000.00-$117,500.00 1 week ago New York, NY $60,000.00-$110,000.00 1 month ago Senior Software Engineer - Supply Quality
New York, NY $200,000.00-$300,000.00 1 week ago Jersey City, NJ $103,330.00-$128,656.00 1 week ago We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr
Claims Quality Analyst
role at
MetroPlusHealth 1 day ago Be among the first 25 applicants Join to apply for the
Claims Quality Analyst
role at
MetroPlusHealth Get AI-powered advice on this job and more exclusive features. This range is provided by MetroPlusHealth. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more. Base pay range
$55,000.00/yr - $65,000.00/yr Empower. Unite. Care.
MetroPlusHealth
is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.
About NYC Health + Hospitals
MetroPlus Health
provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus Health 's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus Health
has been committed to building strong relationships with its members and providers.
Position Overview
Claims Quality Auditor is responsible for reviewing claims to determine if payments have been made correctly. This position analyzes data used in settling claims to determine the validity of payment of claims and reports overpayments, underpayments and other irregularities based upon benefit configuration, compliance with provider contract agreements, and Federal, State and Plan’s established guidelines and/or policies and procedures. The incumbent will research, review, and suggest process improvements, training opportunities and is a resource of information to all staff. The incumbent will also perform special projects.
Work Shifts
9:00 A.M – 5:00 P.M
Duties & Responsibilities
Audit daily processed claims through random selection based on set criteria. Document, track, and trend findings per organizational guidelines Based upon trends, determine ongoing Claims Examiner training needs, and assist in the development of training curriculum. Conduct in-depth research of contract issues, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends. Recommend actions/resolutions. Work with other organizational departments to develop corrective action plans to improve accuracy of the claims adjudication processes and assure compliance with organizational requirements and applicable regulations Assist in the development of Claims policies and procedures Provide backup for other trainers within the department Assist in training of new departmental staffs Assist with the research and resolution of audit appeals Asist with external/internal regulatory audits Identify policies or common errors requiring retraining sessions. Participate in quality projects as required. Collect, analyze data, identify trends, write reports (i.e., the monthly and quarterly reports) and present findings to the appropriate claims service management personnel. Other duties as assigned by senior management
Minimum Qualifications
Associate degree required; Bachelor’s degree preferred Minimum of 4 years of experience performing claims quality audits in a managed care setting Expertise in both professional and institutional claims coding, and coding rules required. Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and standard industry reimbursement methodologies required. Strong knowledge of CMS Medicare and NYS regulations required. Experience in training development and presentation preferred Must have excellent interpersonal, verbal, and written communication skills
Professional Competencies
Strong organizational, analytical, and oral/written communication skills required. Proficiency in PC application skills, e.g., excel, word, PowerPoint, etc., Must be able to follow direction and perform independently according to departmental Integrity and Trust
Benefits
NYC Health and Hospitals offers a competitive benefits package that includes:
Comprehensive Health Benefits for employees hired to work 20+ hrs. per week Retirement Savings and Pension Plans Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts Loan Forgiveness Programs for eligible employees College tuition discounts and professional development opportunities College Savings Program Union Benefits for eligible titles Multiple employee discounts programs Commuter Benefits Programs
#MHP50
Seniority level
Seniority level Mid-Senior level Employment type
Employment type Full-time Job function
Job function Quality Assurance Industries Hospitals and Health Care Referrals increase your chances of interviewing at MetroPlusHealth by 2x Sign in to set job alerts for “Quality Analyst” roles.
Jersey City, NJ $54,500.00-$100,300.00 1 day ago Edison, NJ $70,000.00-$105,000.00 2 weeks ago Audit (Business and Finance) | Analyst | New York
Bronx, NY $63,999.94-$79,999.92 3 weeks ago New York, NY $55,000.00-$65,000.00 4 days ago Internal Audit-New York-Analyst-Enterprise Risk Management - Business Liaison
SENIOR QUALITY ASSURANCE AUTOMATION ENGINEER
New York City Metropolitan Area 12 hours ago Technology Analyst 1 (Quality Assurance) - Project Assistant
New York, NY $86,681.00-$109,650.00 1 week ago Technology Analyst 1 (Quality Assurance) - Project Assistant
New York, NY $86,681.00-$109,650.00 1 week ago Analyst, Sports Business Development & Innovation
New York, NY $87,682.00-$120,560.00 1 week ago Business Automation Integration Analyst - Advertising Ops
New York, NY $83,000.00-$97,000.00 1 week ago Jersey City, NJ $82,493.00-$107,241.00 3 weeks ago New York, NY $88,000.00-$125,000.00 3 weeks ago Technology Analyst 2 (Quality Assurance) - Project Assistant
New York, NY $96,336.00-$121,413.00 1 week ago Senior Quality Engineer (Wayne, NJ) Defined Term
Wayne, NJ $100,000.00-$115,000.00 1 week ago Manufacturing Planner / Inventory Analyst
East Rutherford, NJ $66,600.00-$104,610.00 1 week ago Technology Analyst 2 (Quality Assurance) - Project Assistant
New York, NY $96,336.00-$121,413.00 1 week ago Global Supply Chain Analyst - Regulatory & Quality
Allendale, NJ $56,000.00-$84,000.00 2 weeks ago New York City Metropolitan Area 2 days ago New York, NY $77,000.00-$87,000.00 1 week ago New York, NY $140,000.00-$170,000.00 2 weeks ago New York, NY $94,000.00-$117,500.00 1 week ago New York, NY $60,000.00-$110,000.00 1 month ago Senior Software Engineer - Supply Quality
New York, NY $200,000.00-$300,000.00 1 week ago Jersey City, NJ $103,330.00-$128,656.00 1 week ago We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr