Quality Assurance Claims Review Specialist

JOB OVERVIEW

JOB TITLE:  Quality Assurance Claims Review Specialist

DEPARTMENT:  Corporate Compliance

LOCATION:  Buffalo, NY

DIRECT SUPERVISOR:  Corporate Compliance Coordinator


GENERAL JOB DESCRIPTION

This position will work as a member of the Quality Assurance / Corporate Compliance team assisting with the monitoring, adjustment and correction of claims and other claim related data.


SPECIFIC DUTIES & RESPONSIBILITIES

  1. Maintain current knowledge of Medicaid Managed Care payer processes.
     
  2. Research and follow through with third-party vendor requests for outstanding invoice information and corrections.
     
  3. Quality Assurance accounts receivable follow-up, including monitoring replacement claims, resubmissions and appeals.
     
  4. Track claims via HIPAA5010 transaction files, Electronic Remittance Advice, Explanation of Benefits, and other remittance files.
     
  5. Assist the Accounting Liaison with review of claim denials and work with 3rd party vendors to resubmit invoices, file appeals or adjust accounts according to established policy and procedure.
     
  6. Provide reports with identification of payment and denial trends.
     
  7. Audit claims and escalate identified issues for internal workforce corrections and education.
     
  8. Collaborate with AR Manager to verify the validity of invoices received by third-party vendor regarding per member per month calculations.
     
  9. Provide process improvement recommendations to enhance efficiency and effectiveness of the interdepartmental payment workflows.
     
  10. Perform timely and accurate review of consumer and workforce information within all databases.
     
  11. Review monthly eligibility checks for service participants.
     
  12. Provide quality assurance support for finance projects and initiatives.
     
  13. Conduct investigations, assessments, and audits to assess compliance with applicable billing requirements and claims submission completion.
     
  14. Work cooperatively with other department employees as needed to secure payments, including customer service, accounting, billing, program, and others as needed.
     
  15. Assure accurate and timely documentation of consumer services and required paperwork in Western New York Independent Living, Inc’s (WNYIL’s) Electronic Consumer Record (ECR) database and assure that this task is completed within two (2) working days of the date of service.
     
  16. Attend Agency’s in-service training and staff meetings as well as any other agency related activities as required.
     
  17. Participate in maintaining a neat, clean and safe work environment.
     
  18. Perform other job-related duties as assigned by the supervisor.

EDUCATION & TRAINING

High school diploma or equivalent required
            OR
Associate Degree

Professional and life experience may be considered in lieu of, in full or part of academic credentials.


KNOWLEDGE & EXPERIENCE (if required)

  • High school diploma or equivalent requires three (3) years’ experience in the Human Services field.
     
  • Experience working with electronic claims data and billing required.

SKILLS & ABILITIES

  • Must have intermediate level of knowledge of computers including the use of Excel spreadsheets, databases, word processing and networks.
     
  • Perform in a professional, conscientious, and efficient manner for the purpose of ensuring a better quality of life for persons with disabilities.

WORKING CONDITIONS

WORK ENVIRONMENT:  Office

PHYSICAL DEMANDS OF THE JOB:  Sitting for extended periods of time.
Occasional lifting of not more than 15 pounds.

HOURS / SHIFTS:  M - F 8:30 a.m. – 5:00 p.m.
37.5 - 40 hours per week.

CLASSIFICATION:  Full-time, salary, non-exempt, Professional staff.
Range: $38,000 - $40,000

BENEFITS:  Agency provided group health insurance.
Vision, dental, life, supplemental insurances available.
PTO and paid holiday package. 403(b) retirement with Agency match.
Employee Assistance Program.

OTHER:  Western New York Independent Living, Inc. values our employee safety and follows all recommended NYS required Infectious Disease Prevention Protocols.
Western New York Independent Living, Inc. is an Equal Opportunity Employer.
Reasonable accommodations will be made for people with disabilities.
Western New York Independent Living, Inc. is a scent-free agency.


POSTING INFORMATION

Closing Date:  February 10, 2023

Cover Letter and Resume Required to:

Tina Brown, CHRCO
WNY Independent Living, Inc,
3108 Main St.
Buffalo, N.Y. 14214
Employment@wnyil.org