Quality Assurance Representative

Pembroke Pines, FL

Posted: 10/04/2018 Employment Type: Temp to Full Time Industry: Quality Control/Assurance Job Number: 72504 Pay Rate: $16.83/HR

About:

Our client is a leading certified provider of cost containment and medical risk management solutions in the South Florida area. This organization has been a pioneer in the delivery of managed care and cost containment services to many of the world’s leading insurance and assistance companies while setting the industry standard for quality customer service, medical management, and competent claims administration

 

The Position: 

We are seeking a Claims Quality Assurance Representative who will coordinate the daily work on assigned clients to process claims. This role will be primarily responsible for conducting investigations, evaluations and disposition of coverage on assigned accounts. 

 

Responsibilities:

  • Must become proficient in assigned client’s policies and procedures while possessing comprehension of all types of medical claims billing and ICD-9/10 and CPT codes
  • Identifies and corrects potential claim problems, such as balance billing or incorrect re-pricing
  • Monitors, scores, and reports data to various departments while providing coaching and training to Claims Personnel to improve performance
  • Resolves all types of problem claims and ensures that claims are processed according to policy guidelines with a focus on turnaround time, accuracy and maximization of discount opportunity
  • Conducts bill reviews for all claims and conducts random sample audits for QA purposes
  • Reviews medical records for claims adjudication purposes
  • Interprets and implements quality assurance standards and evaluates their adequacy
  • Conducts and documents internal audits and other quality assurance activities
  • Coordinates and supports on site audits conducted by external providers
  • Follows up with audit finds to ensure corrective actions are being taken
  • Analyzes data to identify areas for improvements in the Quality System
  • Prepares reports to communicate outcomes of quality activities
  • Conducts risk management activities to monitor and mitigate non-conformance occurrences

 

Company benefits often include: 

  • Company sponsored health, GAP, dental and vision insurance @ 100% employee coverage (select a lower plan and it helps to cover dependents as well)
  • Company sponsored short term and long term disability
  • Generous paid time off
  • 401K with company contribution @ 4% after 1 year with the company
  • Tuition reimbursement after 2 years
  • Multi-cultural, family oriented environment
  • The opportunity for internal growth within the company 

 

Interested? Apply directly now or give us a call at (Dade: 305-595-3800 / Broward: 954-437-0070) Questions about this role or others? Email karlha@cxcinc.com 

 

*CAREERXCHANGE® is an equal opportunity employer. We will present the most qualified candidates to our clients based on the skills required to perform the job. For additional opportunities please visit www.careerxchange.com.

  • Prior experience in health care and insurance field for medical claims
  • Complete Knowledge of ICD-9/10 and CPT procedure codes and all other insurance coding methodologies
  • Computer skills necessary to work effectively: Windows Microsoft Word and Excel.
  • Knowledge of Quality Assurance a must
  • Bilingual (English & ANY OTHER SECOND LANGUAGE)
  • Exposure/knowledge of International Billing a plus

Karlha Ludewig
Talent Acquisition Manager

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