Claims Analyst Lead

Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.

Best People, Best Solutions, Best Results

Job Summary:

Senior level professional performs high-level medical record and claims review for Medicaid, or other claims data in order to ensure that proper guidelines have been followed and acts as a facilitator as well as a case manager regarding potential overpayment, fraud, waste, and abuse with regards to Medicaid, and other medical claims.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Review Explanation of Benefit (EOB) cases, beneficiary, provider, and pharmacy cases for potential overpayment, fraud, waste, and abuse.
• Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
• Effectively identifies claims issues and determines root cause.
• Interacts with beneficiaries, health plans, and medical service providers to obtain additional case specific information, as needed.
• Consults with Benefit Integrity experts for advice and clarification.
• Completes inquiry letters, investigation finding letters, and case summaries.
• Refers all potential fraud leads to the Investigators/Auditors.
• Has basic understanding of the use of the computer for entry and research.
• Responsible for case specific or plan specific data entry and reports.
• Participates in internal and external focus groups and other projects, as required.
• Identifies opportunities to improve processes and procedures.
• Has the responsibility and authority to perform their job and provide customer satisfaction.
• May participate as an audit/investigation team member for both desk and field audits/investigations.
• Testifies at various legal proceedings as necessary.
• Highly proficient in applying a large variety of more complex concepts, practices and procedures within the field.
• Relies on extensive experience and judgment to plan and accomplish goals.
• Performs a variety of the more complex tasks requiring a wide degree of creativity and latitude.
• May lead or direct the work of others, providing training and quality assurance for their work.
• Provides job specific orientation and training when called upon. With the Technical Trainer, the manager or others to develop training content, resources and programs specific to job functions.
• Documents records of training that include scheduling, registration and attendance, quality control of training products and evaluation summaries.

Supervisory Responsibilities:

May directly supervise employees. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

To perform the job successfully, an individual should demonstrate the following competencies:

• Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data.
• Problem Solving - Gathers and analyses information skillfully; Identifies and resolves problems.
• Judgment - Supports and explains reasoning for decisions.
• Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
• Written Communication - Writes clearly and informatively; Able to read and interpret written information.
• Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
• Managing People - Includes staff in planning, decision-making, facilitating and process improvement; Takes responsibility for subordinates' activities; Makes self available to staff; Provides regular performance feedback; Develops subordinates' skills and encourages growth; Solicits and applies customer feedback (internal and external); Fosters quality focus in others; Improves processes, products and services.; Continually works to improve supervisory skills.
• Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.

Education and/or Experience

• A BSN OR an RN with additional current and active degree/license/certification/s in a relevant healthcare discipline (i.e., CPC, CPHM, CCM, CFE, HCAFA).
• Minimum five years clinical experience.
• Healthcare experience that demonstrates expertise in conducting utilization reviews, ICD-9 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations preferred.
• Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.

Certificates, Licenses, Registrations

• Current, active and non-restricted RN licensure required.

Travel Requirements

• Depending on contract requirements, regular travel required, including overnight travel of up to 5 days per month which may require use of personal/rental vehicle for travel within the region.

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.