Company :Highmark Inc.Job Description :
GENERAL OVERVIEW:
The Quality analyst is responsible for compiling and analyzing data relevant to the handling of all types of complex adjusted claims; conducting reviews of all organizational or functional activities related to fraud/abuse perpetrated by providers, subscribers, facilities, pharmacies, provider employees and/or employees of the company and ensuring Highmark compliance with all adjustment processes based on SOX remediation and Regulatory and legal guidelines. In addition, the Analyst will identify potential areas of processing vulnerability through procedure review and report trending/analysis; generate reports for analysis and/or sampling; review audit samples for accuracy and appropriateness; train operational staff on processes, act as the subject matter expert for all audit adjustment processes for workgroups, recommend and implement process changes, and coaching quality review staff. As a result of the analysis and sampling activity, the position will develop reports detailing the findings and trending results on a monthly basis while also recommending any processing enhancements and/or internal control improvements.
ESSENTIAL RESPONSIBILITIES:
1. Ensure the consistent, accurate, efficient, and appropriate processing of adjustments and/or duplicate claims through an audit sampling review process.
2. Develop management reports detailing the review process findings as well as trending/analysis reports
3. Monitor and train quality and operational staff
4. Identify any potential fraudulent activity relating to adjustment and/or duplicate claim processing and address any and all deficiencies to remain compliant and report non compliant areas
5. Other duties as assigned or requested.
QUALIFICATIONS:
Education, Licenses/Certifications, and Experience
- High School Diploma/GED
- 3-5 years of relevant, progressive experience in the area of specialization. Exempted experience requirements effective August 2016.
- Experience in claims and/or inquiry processing or equivalent experience in quality
- Experience with Microsoft Office Products
Preferred
- Bachelor’s Degree
Knowledge, Skills and Abilities
- Detailed understanding of the various claims and inquiry processing arrangements, the related Member Touchpoint Measures (MTM) performance standards, and process improvement methodologies
- Working knowledge of various company related benefits, payment policies and procedures, medical terminology, profile mechanisms, and medical policy guidelines.
- Strong background in both verbal and written communication, interpersonal skills, and organizational, problem solving, analytical, interpretative, evaluative and creative skills and abilities.
- Proficiency with reporting and analytical software tools and a strong knowledge of systems utilized throughout the company Operations Division
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
No
WORK ENVIRONMENT
Is Travel Required?
No
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$22.71
Pay Range Maximum:
$35.18
Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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Top Skills
What We Do
Highmark Health, a Pittsburgh, PA based enterprise that employs more than 40,000 people who serve millions of Americans across the country, is the second largest integrated health care delivery and financing network in the nation based on revenue. Highmark Health is the parent company of Highmark Inc., Allegheny Health Network, and HM Health Solutions. Highmark Inc. and its subsidiaries and affiliates provide health insurance to nearly 5 million members in Pennsylvania, West Virginia and Delaware as well as dental insurance, vision care and related health products through a national network of diversified businesses that include United Concordia Companies, HM Insurance Group, and Visionworks. Allegheny Health Network is the parent company of an integrated delivery network that includes eight hospitals, more than 2,800 affiliated physicians, ambulatory surgery centers, an employed physician organization, home and community-based health services, a research institute, a group purchasing organization, and health and wellness pavilions in western Pennsylvania. HM Health Solutions focuses on meeting the information technology platform and other business needs of the Highmark Health enterprise as well as unaffiliated health insurance plans by providing proven business processes, expert knowledge and integrated cloud-based platforms.
A national blended health organization, Highmark Health and our leading businesses support millions of customers with products, services and solutions closely aligned to our mission of creating remarkable health experiences, freeing people to be their best.
Headquartered in Pittsburgh, we're regionally focused in Pennsylvania, Delaware, West Virginia and New York, with customers in all 50 states and the District of Columbia.
We passionately serve individual consumers and fellow businesses alike. Our companies cover a diversified spectrum of essential health-related needs, including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative technology solutions.
We’re also proud to carry forth an important legacy of compassionate care and philanthropy that began more than 170 years ago. This tradition of giving back, reinvesting and ensuring that our communities remain strong and healthy is deeply embedded in our culture, informing our decisions every day.
