Claims QA Analyst
Sentara | |
life insurance, vision insurance, parental leave, paid time off, sick time | |
United States, Florida, Miami | |
April 17, 2024 | |
City/State Doral, FLOverview Work Shift First (Days) (United States of America)AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Claims QA Analyst in Miami and/or Gainesville, Florida. This is a hybrid position, 2 days in office and 3 days remote. Scope of position:The Claims QA Analyst conducts audits of AvMed, Delegated Vendors, and Business Process Outsourcing (BPO) claims. The Claims QA Analyst conducts claims audits and works closely with the BPO to identify and correct any audit findings. Essential Job Functions:
Minimum Requirements:
Preferred Requirements:
Our Benefits:
Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Benefits - Sentara (sentaracareers.com) Keywords: Talroo-Health Plan, #INDEED, Auditing, Claims, Configuration Job Summary Expected to work closely with the Manager, other clinical and QI staff to assure the overall success of the Healthcare Effectiveness Data and Information Set (HEDIS) Project, appropriateness of care and other QI Projects as assigned. Primarily responsible for conducting medical record reviews, data entry and abstraction of data for HEDIS measures, appropriateness of care and other quality initiatives to meet regulatory and contractual requirements for the health plan.Must possess the knowledge to determine the appropriateness of care according to Virginia Medicaid standards. Bachelor's level degree in nursing (BSN) required for positions in Quality and Behavioral Health departments. Master's level degree in Social Work, Psychology or Counseling for Behavioral Health departments in lieu of BSN, with LCSW, LPC or LMFT required. Qualifications: BLD - Bachelor's Level Degree: Nursing (Required), MLD - Master's Level Degree: Counseling, MLD - Master's Level Degree: Psychology, MLD - Master's Level Degree: Social Work Driver's License - Certification - Other/National, Driver License - Certification - North Carolina Division of Motor Vehicles (NCDMV), Driver License - Certification - Virginia Department of Motor Vehicles (VDMV), Licensed Clinical Social Worker (LCSW) - State license - North Carolina Social Work Certification and Licensure Board (NCSWCLB), Licensed Clinical Social Worker (LCSW) - State license - Virginia, Licensed Marriage and Family Therapist (LMFT) - State license - North Carolina, Licensed Marriage and Family Therapist (LMFT) - State license - Virginia, Licensed Professional Counselor (LPC) - State license - North Carolina, Licensed Professional Counselor (LPC) - State license - Other/National, Licensed Professional Counselor (LPC) - State license - Virginia, Registered Nurse (RN) Single State - Nursing License - North Carolina, Registered Nurse (RN) Single State - Nursing License - Virginia ClinicalSkills Microsoft OfficeSentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves. Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application. In support of our mission "to improve health every day," this is a tobacco-free environment. |