The purpose of the Quality Assurance Specialist position is to help drive quality and productivity in the production of medical claims data and to assure both accuracy and timeliness in all CBO claims submissions. The Quality Assurance Specialist will specifically focus on adherence to all USAP billing compliance policies and maintain strict oversight of governmental payer requirements. This will be done through designed process audits, written reports and analysis of the reports as needed. Work products and outputs will include detailed audits and reports to identify process and quality deficiencies, analysis and recommended plans of actions to improve audited processes, as well as to prescribe training needs. The Quality Assurance Specialist will assist Management in routine reviews of policies and procedures and the implementation of improvement plans as needed.
- Complete audit analysis and reports at the individual, department and division level based on defined position pathways and individual / department performance and quality metrics.
- Identify specific individual and department training needs and opportunities for performance improvement through a defined audit analysis program and assist in ongoing process improvement opportunities through audit analysis.
- Audit work in the Charge Entry, Payment Posting and Collections Departments to determine compliance with Policies and Procedures.
- Assist in development and implementation of education programs based on identified quality or productivity issues.
- Provide follow up review of policy changes and implementation of those changes into audit process and reporting.
- Maintain current knowledge of Medicare, Medicaid, Work Comp guidelines and rules.
- Assist with internal and external compliance audits, account reviews on an as-needed basis.
- Work with process improvement team to improve quality and performance through process improvement initiatives.
- Maintain strictest confidentiality.
- Performs other duties, as assigned
- High School diploma or equivalent.
- Associate’s or Bachelor’s degree in a business or health related field is preferred.
- Must have minimum of 2 years billing or collections experience in the health care field.
- Excellent verbal and written communication skills
- Ability to prioritize work
- Understanding of CPT/ASA, ICD-9/10, and HCPCS coding
- In-depth knowledge of Medicare, Medicaid, Workers Compensation guidelines and
- In-depth knowledge of the MSI patient accounting system and report writing
- In-depth knowledge of anesthesia billing
- In-depth knowledge of chronic/acute pain billing
- Detailed audit approach and methods for testing accuracy and compliance to defined
- billing guidelines
- Analytical skills to summarize audit findings into statistically meaningful reports
- Ability to work effectively and independently with staff, physicians, and external
- Must have strong keyboard skills with knowledge of Microsoft Word, Excel and
- Must have a pleasant disposition and high tolerance level for diverse views, varied skill levels, and positions
- Ability to work independently with minimal supervision.
- Ability to read, write, and speak English