Lead Quality Assurance Specialist
Health Care that Starts with You!
Join a truly mission-driven organization! Independent, nonprofit UCare is recognized as one of the Minnesota’s leading health plans. We provide more than 225,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs. UCare is growing in size, membership, products, geographic coverage, and employees. We’re an organization that’s going places. Be part of a team that cares about you, be part of UCare.
The Lead Quality Assurance Specialist will participate in the audit program for the Claims Department staff and claims processing system. Conduct daily audits of processed and adjusted claims. Responsible for conducting quarterly end-to-end, delegated, focused, high dollar, interest audits, audit teams memebrs questions and training of new hires. Serve as internal department resource and contact for questions regarding complex claim requests and issues. Specific duties and responsibilities include:
- Understand and accurately interpret UCare member and provider contracts, policies and procedures, as well as DHS, CMS and WPS rules and regulations.
- Prepare, conduct and analyze 3%-4% user audits to ensure staff's technical competence. Provide feedback and follow up support as needed.
- Maintain audit results in spreadsheet format. Audits are completed daily for the previous day's claim processing. The results are to be entered each day pending any rebuttals. Respond to audit rebuttals within 24 hours of receipt.
- Collaborate with supervisor to develop, implement, and maintain training programs and resources for staff. Ensure timely and accurate delivery of training programs for new and existing staff.
- Serve as a liason between team members and supervisor. Escalate specific claim issues and concerns as appropriate to leadership. Assist in answering questions as needed.
- Conduct quarterly end-to-end audit on random sample of claims. Review for clerical, financial and benefit accuracy, review provider billing accordance to terms of contract and analyze reimbursment schedules for proper system configuration.
- Complete the initial findings report for end-to end and distribute to appropriate departments. Review any rebuttals. Complete final report with cover sheet for the end-to-end and focused audits. Complete system data requests as needed upon final approval of audit.
- Assist in the identification of potential improvements in automated or manual processes to enhance claims processing, including improvements to policies and procedures.
- Report identified trends and/or system related issues to Claims Supervisor - Support.Conduct annual delegated business partner audits such as DentalQuest, ESI and ChiroCare, report on findings, and create corrective action plans as needed.
Two-year Associates degree preferred. Related experience will be considered in lieu of a 2 year degree.
Required experience includes: Three or more years experience in HMO and/or claims processing, CPT and ICD-9 coding, and medical terminology required. Knowledge of Medicaid, General Assistance, Medical Assistance, Minnesota Care and Medicare required. Preferred experience includes: Auditing experience preferred. Knowledge of CMS, Medicare and DHS rules and regulations. Amisys, Macess and Excel experience preferred.
Enter a highly collaborative environment where people are truly engaged, and feedback is valued. You’ll enjoy a competitive salary and benefits, as well as a host of other perks, including a nationally recognized wellness program, and a bright, open, award-winning office space in Northeast Minneapolis—just minutes from major freeways and retail centers.
At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.