Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Quality Assurance Specialist is responsible for ensuring that the non-contracted provider appeals meet the established standards set by the department and regulatory requirements. This position will perform quality reviews to ensure all provider appeals are processed timely and accurately. The QA Specialist will also document audit findings and identify areas of improvement and/or training opportunities and prepare and submit performance reports and other required departmental reports to Management.

RESPONSIBILITIES:

· Reviewing non-contracted provider appeals to ensure accuracy and compliance.

· Validate accuracy and appropriateness of letters and other correspondence being sent to providers according to department and CMS guidelines.

·Validate payment of overturned cases for accuracy.

· Recognize, identify training issues, error trends and report findings to Management.

· Work with the Recovery Department for resolution of any identified overpayments.

· Assist in preparing and reviewing cases for regulatory and other health plan audits.

· Validate integrity and accuracy of data outputs for all Provider Appeals reporting.

· Recognize potential system issues and process improvements relating to provider appeals data.

· Prepare and submit Appeal Specialists’ monthly quality performance reports to management.

· Prepare and disseminate internal management reports accurately within the required time frames.

· Support department initiatives in improving processes and workflow efficiencies.

· Adhere to all regulatory and company standards, as described in the Employee Handbook and departmental Policies and Procedures.

· Comply with the company’s time and attendance policy.

· Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.

· Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.) and teamwork.

· Perform additional related duties as assigned by Management.

REQUIREMENTS:

Minimum Experience:

a. 3+ years auditing of medical claims or provider dispute experience preferably in health plan setting

b. 3+ years experience in examining all types of Medicare Part C (medical) claims and/or provider dispute and appeals processing.

Education/Licensure:

High school completion or GED required

Other:

a. Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.

b. Understanding of different payment methodology such as Medicare PPS (MS-DRG, APC, etc.), Medicare Physicians fee schedule, Per Diem, etc., coding edits and coordination of benefits.

c. Excellent verbal and written communication skills, ability to speak effectively before groups of customers or employees of the organization.

d. Computer skills: Intermediate to Advance Microsoft Excel and Word

e. Reasoning skills: ability to apply critical thinking skills and common sense understanding to successfully interpret issues and develop resolution.

f. Ability to work under pressure and deliver.

g. Strong attention to detail and analytical skills

h. Excellent organizational skills and ability to multi-task

i. Ability to work independently.

PREFERRED QUALIFICATIONS:

Education/Licensure: a. Bachelor’s degree preferred

Other:

a. Understanding of Medicare Advantage provider appeals and dispute process.

b. Ability to interpret provider contracts to ensure claims payment accuracy.

c. Understanding of Division of Financial Responsibility on how they apply to claims processing.

d. Computer skills: Microsoft Access and EZCAP experience preferred.

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran. If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact careers@ahcusa.com.

Pay Range: $44,790.00 - $67,185.00

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com.