Associate Quality Assurance Specialist - Operations

Job Title: Associate Quality Assurance Specialist | Operations | Sioux Falls

City: Sioux Falls

State: South Dakota

Department *: * Operations

Job Schedule: Full Time

Shift: Days

Hours Per Shift: 8 hr

JOB SUMMARY

Will perform daily claims Pre and Post claim audit through random sampling of claims payment runs verifying eligibility, benefits and pricing. Inaccuracies will be documented and reported further analysis. and test execution of provider contracts and benefits to ensure accurate and timely claims payments consistent with the Sanford Health Plan policies and contracts. Audit functions will include: new provider/vendor/contract system setup, provider fee schedules and pricing, and high cost claim reports. Demonstrate knowledge in coordination of benefits and third party reimbursement, group and individual health insurance products, including Medicare and Medicaid programs. Will be responsible for completing comprehensive configuration testing processes for provider contracts and/or benefits. Evaluates results for documented feedback on processes. Communicates outcomes of the results. Must have skills in analyzing data, excellent written and oral communication. Must be able to work independently, multitask, work in fast pace environment and manage stress well. Maintains health working relationships with interdepartmental teams.

POSITION RESPONSIBILITIES

Addresses documentation issues to support claim processing that is in-line with regulations and rules. Adheres to organizational quality management processes and practices. Follows the company's claims standards when dealing with coverage issues. Identifies the basic eligibility and enrollment requirements. Monitors compliance with contract specifications and regulations. Participates in audits of specific processes or functions. Reviews benefits reports and analyzes financial aspects of recommended alternatives. Utilizes major tools and techniques for processing claims, from claims receiving to compensation releases. Utilizes specific approaches and tools for checking and cross-checking outputs.

DEPARTMENT DETAILS

Ability to divide your time between duties.
Meticulous attention to detail.
Excellent problem-solving skills.
Ability to work to deadlines under pressure, dependable, ability to make independent decisions.
An auditor's decision should not be wavered or influenced by anyone.
Have following work ethics: flexibility, determination, persistence, self-motivation, confidence, and honesty.

QUALIFICATIONS

High school diploma required. Associate degree preferred. Minimum of three years medical claims processing and insurance required. Knowledge of provider contracts, provider fee schedules and pricing, eligibility, enrollment and disenrollment desired.

About Sanford Health:

At Sanford Health, we are dedicated to the work of health and healing.
Every day, we show that commitment by delivering the highest quality of care to the communities we serve.
We are leaders in health care and strive to provide patients across the region with convenient access to expert medical care, leading-edge technologies and world-class facilities.
In addition to strong clinical care, we are also committed to research, education and community growth.
We engage in medical research to not only discover innovative ways to provide care, but also cures for common diseases.
We continuously seek new ways to achieve our vision of improving the human condition here in your community,
across the region and around the world.
The entire team at Sanford Health recognizes the value of healthy families and communities.
We continue to gain momentum and expand our reach. Together, we can make a positive difference now, and in the future.
Sanford is an EEO/AA Employer M/F/Disability/Vet.
If you are an individual with a disability and would like to request an accommodation for help with your online application,
please call 1-877-673-0854 or send an email to talent@sanfordhealth.org .
In compliance with federal law requiring employers to verify new employees' U.S.
employment eligibility, Sanford participates in E-Verify. To learn more click here for English Version at https://e-verify.uscis.gov/emp/media/resourcesContents/EverifyPosterEnglish.pdf or here for Spanish Version at https://e-verify.uscis.gov/emp/media/resourcesContents/EverifyPosterSpanish.pdf .

City: Sioux Falls

State: South Dakota

Job Function: Health Plan

Job Schedule: Full Time

Shift: Days

Req Number: req23392