As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
The Quality Control Analyst is responsible for claims auditing and identifying examiner and system errors. This position also handles the auditing of claims special projects including risk pool, shared risk, Health Plan.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
Understands, interprets and applies coding and reimbursement guideline; provider and Health Plan contracts for professional claims to ensure accuracy. Review of complex and high dollar claims to determine financial and risk accuracy and in depth review of written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers.
Identifies potential issues related to system configuration, benefits, eligibility, authorizations, etc. affecting the Claims Departments ability to process claims accurately and forwarding those issues to the correct internal department, attaching all necessary documentation, to ensure the system is updated, as appropriate and follow-up with these departments
Creates clear and accurate audit findings and recommendation in written audit processing status codes that provides feedback to examiners used in examiner scorecard, identifies error trends and training opportunity.
Audits system configuration for new client implementation and provider or Health Plan contracts and amendments.
Retrospective auditing of paid claims on a quarterly basis. This includes flagging of overpaid claims for recovery.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Strong knowledge and understanding of Managed Healthcare.
Excellent communication skills, written and verbal.
Ability to create clear and concise audit reports and maintain productivity standards
Must be detail oriented and have the ability to work independently
Must display excellent interpersonal skills
Ability to demonstrate initiative and discipline in time management and assignment completion
Ability to work in a virtual setting under minimal supervision
Must be well versed in reading Health Plan DOFRs and understand all types of fee schedules, including risk pools.
Excellent knowledge of CPT, RBRVS, DRG, HCPCS and ICD-9, ICD-10 coding and regulations.
Include minimum education, technical training, and/or experience preferred to perform the job.
Bachelorï¿½s degree in Finance or Accounting or equivalent experience.
High school diploma or equivalent required
5 years of experience as a Quality Control Analyst.
2-3 years of experience as Claims Adjuster
Include minimum certification required to perform the job.
No certificate required
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Light physical effort (lift up to 10lbs). Mostly sedentary work. Regularly needs to be able to bend, stoop and reach to file.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Office Work Environment
Approximately 0% travel may be required
Job: Conifer Health Solutions
Primary Location: Frisco, Texas
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 2005028744
About Conifer Health Solutions
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.