JOB SUMMARY

Perform quality review on claims, enrollment, and customer service personnel on select criteria determined by management. Audit personnel daily of randomly selected output and complete appropriate forms for manager/supervisor feedback. Will work closely with trainer on training needs identified through the quality review process.

KEY RESPONSIBILITIES

Audit claims, enrollment and customer service personnel daily of randomly selected work and complete appropriate forms related to the audits. Answer questions for claims, enrollment and customer service personnel. Establish training needs for employees identified during the quality review process. Perform other job-related duties as assigned.

QUALIFICATIONS

Ability to read and have a clear understanding of claims processing manuals, medical terminology, CPT codes and perform claims processing procedures. Knowledge of claims processing manuals and health benefit booklets. Excellent interpersonal skills and the ability to work with individuals at all levels in the organization. Successful completion of Health Care Sanctions background check. Ability to perform detailed math calculations. Proficient in Microsoft Office applications. Self-motivated with the ability to handle multiple tasks, work independently with minimal direction and meet stringent deadlines. Possess strong oral and written communication skills.

EDUCATION/EXPERIENCE

High school diploma or equivalent required. Associates degree preferred. Four years claim related processing experience. One to two years quality review/auditing experience preferred. CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin