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Job Description

Essential Functions

Duties and Responsibilities

• Conducts Claims audits to ensure claims processors:
  • Identifies and escalated complex bills per documented guidelines.
  • Codes provider bills in accordance with program guidelines
  • Pay providers in an accurate and timely manner
• Provides input to SGS managers and teams regarding analysis, updates, and recommendations for modifications for procedures and processes to continually improve operations and protocols.
• Assist with collection and summary of data in collaboration with SGS Quality Committees, identifies opportunities for improvement, and presents findings.
• Understands each contract's clinical quality assurance requirements and monitors compliance, in collaboration with the SGS analytics and management teams.
• Performs standard and ad hoc audits of claims activities, as directed by quality committees.
• Assists with performance improvement activities.
• Tracks client complaints and issues to resolution, in collaboration with the Account Managers.
• Identifies new areas that need quality monitoring, on a short-term or continuous basis.

Number of openings 2 openings Location remote

Work hours 8:30 5:30 EST with 1 hr. lunch

Job Specifications

Education

• High School diploma or GED required.

Experience

• One (1) year of bill review or claims processing experience or an equivalent combination of education and experience is required. Knowledge of medical terminology is preferred.
• One (1) year of quality management or auditing experience, preferred.
• Federal Employees Compensation Act (FECA) experience, preferred.
• Medicare/Medicaid rules and regulations experience, preferred.

Other Skills and Abilities, Qualifications

• Excellent oral and written communication
• PC literate, including Microsoft Office products.
• Analytical and interpretive skills.
• Strong organizational skills.
• Good interpersonal skills.
• Ability to work in a team environment.
• Ability to meet or exceed Performance Competencies