Why This Role is Important to Us:

Position Summary:

Reporting to the VP Quality & Controls Assurance, the incumbent is responsible for independent quality reviews of medical claims, and evaluating Call Center activities for compliance with policies and Standard Operating Procedures (SOP). Additionally, this role will review issuance of ID Cards, and Welcome Kits for accuracy. This role will also conduct reviews to verify accuracy of Enrollment entries.

For Call Center reviews, this position will review calls, letters, emails, and other communications associated with Call Center activity. Responsibilities include providing immediate error notices, compiling review results and timely communication to the business area leadership.

For Medical Claim reviews, post-payment review of claims that were manually processed by a Claim Examiner to assess financial and procedural accuracy. Reviews will also be conducted to verify data displayed on EOBs is accurate.

For Enrollment reviews, this position will verify enrollment is entered correctly for Medicaid and Medicare effective dates. This position will also conduct reviews to verify that Welcome Kits and ID Cards were sent timely and correctly.

For all reviews, review results will be summarized and provided to appropriate leadership. Results will be reviewed to identify patterns and to identify root cause, and to provide training and feedback to the appropriate department.

Supervision Exercised:

No, this position does not have direct reports.

What You'll Be Doing:

Essential Duties & Responsibilities:

• Develop in depth knowledge of policies, procedures, and expectations unique to each responsibility and stay abreast of updates, to ensure accurate review of verbal and written communications.

• Aggregate weekly and monthly review results for the Operations area and for Executive level reports.

• Meet standards for completing work timely and accurately.

• Collect and preserve detailed documentation related to reviews and findings.

• Provide feedback on findings to enable improved quality in the future.

• Perform other duties as assigned.

Call Reviews

• Monitor the verbal communications of Member Services, Provider Services, Broker Specialists, Outreach Specialists and all other Contact Center staff through live call monitoring and recordings to ensure staff compliance with policies, procedures and regulations.

• Complete required monitoring documentation, such as the call observation form or call monitoring scorecard, to capture successes and areas for improvement.

• Monitor the written communications of Member Services, Provider Services, Broker Specialists, Outreach Specialists, Research Specialists, and all other Contact Center staff including emails, letters, chats, member portal messaging, and other types of communication to ensure accuracy, professionalism and compliance with Standard Operating Procedures (SOP).

• Provide immediate audit results to Member Services, Provider Services, Broker Specialists, Outreach Specialists, Research Specialists, and all other Contact Center staff.

• Review work completed in CCA systems to ensure appropriate processes were followed and documentation is complete.

Claims Review

• Understand all claim processing related requirements from Medicaid and Medicare for all CCA offered products.

• Conduct reviews of health care claims and document review findings in accordance with standard operating procedures (SOP).

• Identify claim procedural and financial errors, track results for communication to individual claim analysts, claim management, and aggregated data for executive leadership.

• Track results for claim errors that are appealed and update metrics accordingly.

• Conduct sample reviews of EOBs for accurate information prior to issuance.

Enrollment

• Understand all enrollment related requirements from Medicaid and Medicare enrollment for all CCA offered products.

• Responsible for Enrollment Data Validation (EDV) evidence gathering and documentation submission on CMS dictated timeframes.

• Review enrollment data reports from Medicare, Medicaid, and CCA contracted vendors to validate enrollment accuracy.

• Ensure all CMS enrollment files are reviewed and loaded to the enrollment system as required.

• Understand enrollment specialist workflows.

• Review Welcome Kits for accuracy prior to issuance.

Working Conditions:

• Standard Office Conditions.

• Standard Office Equipment

What We're Looking For:

Required Education:

• Bachelor's Degree or equivalent experience

Required Experience:

• 3+ years’ experience healthcare claims payor experience, enrollment experience and/or Call Center experience

Desired Experience:

• Experience with quality assurance, particularly in the healthcare field.

• Experience coaching for performance improvement

Required Knowledge, Skills & Abilities:

• Must be able to demonstrate productive and independent time management.

• Must possess exceptional oral and written communication skills.

• Knowledge of Market Prominence (Enrollment system)

• Knowledge of Medicare plans (MAPD, DSNP, etc.) and processes

• Understanding of Dual Eligibility, Medicare, Medicaid, and Mass Health.

• Knowledge of CPT, ICD10, HCPCS or other coding structures are required.

• Knowledge of UB-04s, CMS 1500 forms, and itemized statements

• Strong overall Microsoft Office skills with an emphasis on Excel skills

• Excellent collaboration and communication skills with the ability to partner effectively across the organization and with external partners.

• Understanding of individualized complex care plans

• Understands and recognizes medical and insurance terminology.

• Strong project management skills with the demonstrated ability to handle multiple projects.

• Must possess strong Microsoft Office Skills (Word, Excel, Outlook, PowerPoint), and Internet research skills.

Required Language:

• English

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.