Claims Quality Specialist - Presbyterian Healthcare Services

Overview:

Now hiring a Claims Quality Specialist

Responsible for reviewing payable and denied medical and facility claims to measure accuracy of the claims processing function as determined by benefit plan design, provider agreements, and applicable health claims policies and procedures as defined and adopted by Presbyterian Health Plan

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

• Full Time - Exempt: No
• Job is based Rev Hugh Cooper Admin Center
• Work hours: Days
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

Qualifications:

• High School education (GED) required. One to 3 years of experience in claims processing required.
• Demonstrated ability to communicate effectively in person, via telephone and in writing.
• Demonstrated ability to sustain quality and production standards.
• Requires good organization skills, and the ability to analyze reports and system processes.
• Demonstrated ability to function effectively as a team member

Responsibilities:

• Review payable and denied claims and claim adjustments processed by Analysts and Specialists. Claims will be reviewed for procedural and financial accuracy.
• Identify and propose changes to current processing guidelines to maintain quality standards
• Identify claims processing guidelines and policies that require review and clarification, and communicate those issues to the D.A.T.A. Team and Training Department.
• Identify provider billing practices that are inconsistent with Presbyterian Health Plan contractual agreements and communicate those issues to the Provider Relations Departments for follow-up with the provider.
• Identifies patterns in payable, denied and adjusted claims. Identifies errors and inconsistencies that require revisions to claim guidelines, system modifications, or Analyst and Specialist practices.
• Performs tasks individually and as part of an assigned team.
• Participates as an effective and active team member.
• Act as liaison between ITF account regulators/auditors and PHP staff.

Benefits:

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

Maximum Offer for this position is up to:USD $23.07/Hr.Compensation Disclaimer:The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.