Quality Assurance Specialist

Minneapolis, Minnesota
Mar 06, 2013
Mar 06, 2013
Employment Status
Full Time

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 Quality Assurance Specialist will participate in the audit program for the Claims Department staff and claims processing system. Conduct daily audit of processed and adjusted claims. Back-up  for conducting quarterly end-to-end, delegated, focused, high dollar, interest audits, audit teams members questions and training of new hires. Assist in documentation used in training and department policies and procedures.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.
  • Back-up 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.
  • Back-up 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.
  • Inform Claims Support Supervisor of any identified trends and/or system related issues
  • Assist Claims Leadership in answering staff questions as needed.
  • Back-up report on annual delegated business partner audits such as DentalQuest, ESI and ChiroCare. Create corrective action plans as needed.

Two-year Associates degree preferred. Related experience will be considered in lieu of a 2 year degree.

Three or more years experience in HMO and/or claims processing, CPT and ICD-9 coding, and medical terminology is required. Knowledge of Medicaid, General Assistance, Medical Assistance, Minnesota Care and Medicare is also required. Auditing experience preferred. Knowledge of CMS, Medicare and DHS rules and regulations and Amisys, Macess and Excel experience is also preferred.

Knowledge, skills, and abilities required to be successful in this role:

  1. Excellent analytical and problem solving skills.
  2. Excellent interpersonal communication skills.
  3. Strong verbal and written communications skills
  4. Good organizational skills and the ability to meet muluiple priorities.
  5. Exceptional attention to detail
  6. Excellent PC skills and knowledge of PC applications
  7. Ability to effectively train new information.

At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve. EOE/AA


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.

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