Quality Control Examiner

Responsible for daily auditing of claims adjudicated by the Claims Department and batch adjudication to ensure compliance with policies and procedures. Conducts various retrospective claim audits. Adjudicate all types of claims. The Claims Auditor identifies claims problems and proposes solutions.

ESSENTIAL JOB FUNCTIONS:
·Audit of claims adjudicated by the Claims Department.
·Conduct retrospective claim audits to include the 1% audit of all claims paid.
·Interpret policy and procedures to properly adjudicate all types of claims.
·Prepare and submit various claims reports weekly and monthly for use by the Claims Department.
·Troubleshoot system errors on an ongoing basis.
·Identify contractual discrepancies and communicate with Supervisor to ensure that any questions are quickly resolved and claims integrity is sound.
·Perform adjustments on incorrectly processed claims.
·Make computer system inquiries and entries in order to obtain claims-related information, release claims, adjust payments and resolve claims-related problems.
·Ability to negotiate and interact with provider offices via telephone.
·Perform claims analysis requested by management.

Education/Experience:

·High school diploma or equivalent.
·Minimum of two years prior claims processing experience including HMO, PPO, hospital and all other type claims with a full understanding of claims processing guidelines. Some knowledge of COB and pre-existing.