Senior Quality Analyst (Claims)

Summary of Position

• Perform audits and/or provide oversight and guidance to Claim Auditors in completing comprehensive random audits of claims, membership and service inquiry adjustment transactions.
  
• Determine the root causes of error and recommend appropriate corrective actions to prevent re-occurrence of these errors.
  
• Support cross-functional Business Transformation initiatives with quantitative transactional analyses and sample audits.
  
• Support Business Transformation Leaders leading business improvement and integration projects with problem definition and resolution.

Principal Accountabilities

• Perform timely post-payment audits of all claim types to verify the accuracy of the claim payment and processing.
  
• Perform cycle time analysis and audits of EmblemHealth of root cause and corrective actions
  
• Perform comprehensive audits of service inquiry adjustment transactions to verify that inquiries from groups, providers and subscribers are resolved accurately and timely.
  
• Conduct special audits as directed by senior management, including subcontracted operational capabilities.
  
• Provide problem definition/analysis support to the Business Transformation Leaders and their associated process improvements projects.
  
• Review and evaluate management responses and corrective action plans related to audit findings; negotiate disputed findings and recommendations with area management.
  
• Analyze all audit results and identify the root causes of errors.
  
• Develop appropriate and cost-effective recommendations
  
• Work with Claims, PFO, PNM, Membership and IT to identify any required system logic modifications related to audit findings.
  
• Participate in the external audit process, provide instruction to the auditors, research and coordinate responses to specific audit issues or to questions as directed by departmental management.
  
• Perform comprehensive reviews of new product or system implementations, as requested by management.
  
• Verify that applicable system data files are updated and claims are accurately adjudicated in accordance with contractual benefit provisions in conjunction with the reviews.
  
• Regular attendance is an essential function of the job. Perform other duties as assigned or required.