Quality Control Reviewer III

@ 1199SEIU Funds

Job Responsibilities

The Quality Control Reviewer III at 1199SEIU Funds will cross-train Processors and Quality Control Reviewers in the Hospital Claims Department, create advances from providers based on Fraud & Abuse Department findings, and review complex claim issues including 1st, 2nd, and 3rd level (IPRO) appeals.

Other duties include:

• Review and finalize claims per Ceris findings.
• Monitor the QNXT claims processing system to ensure smooth operations including electronic, imaging, eligibility downloads, pricing verification, and pay-to-assignments.
• Handle ESI/eviCore corrected claim reports and correspond with Aetna P.O.S on specific requests.
• Ensure timely and accurate processing of hospital claims across various programs such as Claims Xten, Lab Management, Radiation Therapy, High-End Imaging, Medical Oncology, and Specialty drug programs.
• Conduct system testing for QNXT upgrades and enhancements, and evaluate automated software performance.
• Review Document Management System inquiries, claims spreadsheets, and medical records to resolve claim discrepancies.
• Process and evaluate facility claims manually or via DMS while responding to provider inquiries effectively.
• Resolve call tracking tickets and escalated emails, and perform payment adjustments including overpayments and refund processes.
• Undertake additional duties and projects as assigned by management.

Qualifications

Candidates must have a High School Diploma or GED (college preferred) and at least three years of hospital claims processing experience. Strong knowledge of hospital claims processing, eligibility systems, and Coordination of Benefits (COB) guidelines is essential. Proficiency in Microsoft Excel (and MS Word preferred) along with excellent communication, organizational, and analytical skills are required. The ability to work independently, prioritize tasks under pressure, and effectively manage multiple assignments is crucial.

Key skills/competency

Quality Control Reviewer III, claims processing, hospital claims, QNXT, eligibility, fraud, system testing, document management, communication, analytical