Claims Quality Oversight Analyst

Operations

EmblemHealth

Summary of Position

To oversee the performance of vendors who are delegated for the claims processing function to ensure delegates meet and are aligned with EH standards.

Accountable to perform quality assurance oversight of delegated vendors and administer EH Delegated Vendor Oversight Committee (DVOC) annual audits of the delegated arrangements.

Job Responsibilities

• Administer audits of the delegate claims processing function :
• Request supporting documentation for randomly selected samples of delegate processed claims.
• Work with the RM to ensure that all delegate-provided information is complete prior to commencement of audit.
• Review all documentation and populate DVOC audit tool with claims detail for all selected samples.
• Review delegate's Claims policies & procedures and score the DVOC audit tool for completeness.
• Conduct exit conference with delegates to discuss audit findings.
• Share findings with delegate and review disputes.
• Prepare all applicable audit memos for presentation to the DVOC (audit memo, CAP and CAP updates memos)
• Administer CAPs and monitor to ensure that the corrective plans are completed and tested within timeline.
• Meet with delegates to discuss areas of concern in the timely resolution of identified issues.
• Work closely with RMs to obtain supporting documentation to support delegate's confirmation of resolution.
• Analyze monthly KPI reporting packages received and prepare analysis report to share with delegate for response.
• Ensure completeness and adherence to claims processing TATs and all other designated claims metrics.
• Review for trends adversely impacting claims processing quality and highlight in written analysis.
• Participate in monthly Administrative Operating Committee meetings with delegates to discuss areas of concern within the claims' metrics and status updates on implementation of open corrective actions.

Qualifications