- Conduct 3% random audits on all processed claims post-check disbursement
- Audit all zero pay claims exceeding $10,000 pre-check disbursement
- Audit all claims paying $10,000 or more pre-check disbursement
- Achieve 12 audits per hour with 97% technical, 98% financial, and 98% overall accuracy
- Lead weekly calibration meetings, conduct root cause analysis, provide feedback, and address retraining needs
- Contribute to departmental goals and process improvement plans
- Perform assigned duties effectively
- Education/Specialized Training/Licensure: High school Graduate or GED equivalent
- Work Experience: Minimum 5 years in claims adjudication with 4+ years of auditing experience
- Management Experience: Not required
- Software Proficiencies: PC proficiency, 10-key skills, medical coding, and CPT/HCPC coding
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Sr Claims Quality Assurance Analyst - Houston, United States - Harris Health
![Default job background](https://contents.bebee.com/public/img/bg-user-ex-1.jpg)
Description
JOB SUMMARY
To efficiently review claims for new hires, experienced Examiners, and auto-adjudicated claims. Generate accuracy reports per processor for operations and senior management staff review. Responsible for trending and root cause analysis, providing concise reports to management. Also oversee first level appeals, mentor Examiners and Quality Analysts, and review Provider Communication, Provider Fee Schedule, and Provider Database team.
JOB SPECIFICATIONS AND CORE COMPETENCIES
MINIMUM QUALIFICATIONS: