Manager, Quality Assurance, Training and Recovery

Responsibilities

• Overseeing and managing the Quality Assurance, QNXT Medical, and Hospital Claim Training and Recovery Unit
• Develop and maintain processes for objectively auditing and measuring the performance of individuals, systems, and departments. Ensure compliance with Medical and Hospital Claims Processor requirements and provide feedback to the relevant managers and supervisors. Identify incorrect payments and refer overpayments to recovery staff for recoupment. Educate QA staff to recognize potential fraudulent claim activity.
• Manage staff that conduct training classes for new hires and refresher training to improve the functions of the Medical, Hospital, Provider Relations, Care Management, Utilization, and Staff Claims Departments.
• Oversee staff who contact providers to recoup overpayments from physicians and hospitals that were previously identified by the Quality Assurance staff. Analyze unsolicited refunds to determine the cause and refer to department management for corrective action.
• Promote financial efficiencies and effectiveness within the Fund. Detect and prevent fraud and abuse by providers and members
• Ensure that the Claims Staff have a thorough knowledge of both claims processes and are proficient in performing their essential duties and acquire the skills to achieve the department's goals and objectives.
• To ensure integration of the Fund policies, contracts, and procedures, and that system configuration is being maintained
• Oversee testing related to QNXT upgrades, system enhancements, and external vendor processes
• Perform additional duties and projects as assigned by management

Qualifications

• Bachelor’s Degree or equivalent years of work experience required
• Minimum of five (5) years hospital claims processing, quality assurance, auditing experience required; to include a minimum of two (2) years supervisor experience required
• Intermediate level in Microsoft Excel required, Microsoft Word preferred
• Strong knowledge of CPT, ICD-10, HCPCS, UB-04 and hospital reimbursement methodologies; good understanding of hospital contracts
• Knowledge of eligibility, medical terminology, third-party reimbursement and COB
• Strong leadership skills required; able to make independent decisions concerning management, planning, scheduling, and assignment of work; excellent time management and data reporting skills
• Strong analytical, critical thinking, interpersonal and communication skills (written and oral)
• Excellent organizational skills; able to multi-task, prioritize and follow up and ability to work well under pressure in a fast pace environment