Conifer Health Solutions is a leading healthcare business process management services provider working to improve operational performance for more than 600 clients so they can support financial improvement, enhance the patient experience, and drive value-based performance. Through our revenue cycle management, patient communications, and value-based care solutions, we empower healthcare decision makers—hospitals, health systems, physicians, self-insured employers, and payers—to better connect every point of care and wellness management. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!JOB SUMMARYThe role of the Quality Control Analyst includes auditing medical claims, customer service phone calls, administration of third party subrogation cases, processing of claim adjustments including refunds, reporting state surcharge and the processing of first level appeals.ESSENTIAL DUTIES AND RESPONSIBILITIESInclude the following. Others may be assigned.
- Audits daily professional and facility claims for assigned groups and flags claims for examiner errors. 80%
- Researches system configuration against contracts and flag claims for system configuration errors. 10%
- Audits and tests system configuration changes or new client implementations in the claims system timely. 5%
- Performs retrospective audits identifying overpayments, underpayments and system configuration issues. 5%
KNOWLEDGE, SKILLS, ABILITIESTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Strong knowledge and understanding of Managed Healthcare. Excellent communication skills, written and verbal.Must be well versed in reading health plan DOFRs and understand all types of fee schedules, including risk pools.Excellent knowledge of CPT, RBRVS, DRG, HCPCS and ICD-9 coding and regulations.Software: Microsoft Office, EZ-Cap, McKesson Claim Check, Redbook, DRG Pricing Software
EDUCATION / EXPERIENCEInclude minimum education, technical training, and/or experience preferred to perform the job.High school diploma or equivalent required.3-5 years of experience processing managed health care claims preferred.
PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Must be able to work in sitting position, use computer and answer telephone
WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Office Work Environment
Job: Conifer Health SolutionsPrimary Location: Encino, CaliforniaHospital Location: Conifer Value Based CareJob Type: Full-timeShift Type: Days Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status.
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