Claims QA Analyst
Company: Sentara Health
Location: Miami
Posted on: April 17, 2024
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Job Description:
City/State
Doral, FL
Overview
Work Shift
First (Days) (United States of America)
AvMed, a division of Sentara Health Plans in the Florida market, is
hiring a Claims QA Analyst in Miami and/or Gainesville, Florida.
This is a hybrid position, 2 days in office and 3 days remote.
Scope of position: The Claims QA Analyst conducts audits of AvMed,
Delegated Vendors, and Business Process Outsourcing (BPO) claims.
The Claims QA Analyst conducts claims audits and works closely with
the BPO to identify and correct any audit findings.
Essential Job Functions:
Minimum Requirements:
Preferred Requirements:
Our Benefits:
As the third-largest employer in Virginia, Sentara Health was named
by Forbes Magazine as one of America's best large employers. We
offer a variety of amenities to our employees, including, but not
limited to:
Sentara employees strive to make our communities healthier places
to live. We're setting the standard for medical excellence within a
vibrant, creative, and highly productive workplace. For information
about our employee benefits, please visit: Benefits - Sentara
(sentaracareers.com)
Join our team! We are committed to quality healthcare, improving
health every day, and provide the opportunity for training,
development, and growth!
Note: Sentara Healthcare offers employees comprehensive health care
and retirement benefits designed with you and your family's
well-being in mind. Our benefits packages are designed to change
with you by meeting your needs now and anticipating what comes
next. You have a variety of options for medical, dental and vision
insurance, life insurance, disability, and voluntary benefits as
well as Paid Time Off in the form of sick time, vacation time and
paid parental leave. Team Members have the opportunity to earn an
annual flat amount Bonus payment if established system and employee
eligibility criteria is met.
Keywords: Talroo-Health Plan, #INDEED, Auditing, Claims,
Configuration
Job Summary
Expected to work closely with the Manager, other clinical and QI
staff to assure the overall success of the Healthcare Effectiveness
Data and Information Set (HEDIS) Project, appropriateness of care
and other QI Projects as assigned. Primarily responsible for
conducting medical record reviews, data entry and abstraction of
data for HEDIS measures, appropriateness of care and other quality
initiatives to meet regulatory and contractual requirements for the
health plan.
Must possess the knowledge to determine the appropriateness of care
according to Virginia Medicaid standards.
Bachelor's level degree in nursing (BSN) required for positions in
Quality and Behavioral Health departments.
Master's level degree in Social Work, Psychology or Counseling for
Behavioral Health departments in lieu of BSN, with LCSW, LPC or
LMFT required.
Qualifications:
BLD - Bachelor's Level Degree: Nursing (Required), MLD - Master's
Level Degree: Counseling, MLD - Master's Level Degree: Psychology,
MLD - Master's Level Degree: Social Work
Driver's License - Certification - Other/National, Driver License -
Certification - North Carolina Division of Motor Vehicles (NCDMV),
Driver License - Certification - Virginia Department of Motor
Vehicles (VDMV), Licensed Clinical Social Worker (LCSW) - State
license - North Carolina Social Work Certification and Licensure
Board (NCSWCLB), Licensed Clinical Social Worker (LCSW) - State
license - Virginia, Licensed Marriage and Family Therapist (LMFT) -
State license - North Carolina, Licensed Marriage and Family
Therapist (LMFT) - State license - Virginia, Licensed Professional
Counselor (LPC) - State license - North Carolina, Licensed
Professional Counselor (LPC) - State license - Other/National,
Licensed Professional Counselor (LPC) - State license - Virginia,
Registered Nurse (RN) Single State - Nursing License - North
Carolina, Registered Nurse (RN) Single State - Nursing License -
Virginia
Clinical
Skills
Microsoft Office
Sentara Healthcare prides itself on the diversity and inclusiveness
of its close to an almost 30,000-member workforce. Diversity,
inclusion, and belonging is a guiding principle of the organization
to ensure its workforce reflects the communities it serves.
Per Clinical Laboratory Improvement Amendments (CLIA), some
clinical environments require proof of education; these regulations
are posted at ecfr.gov for further information. In an effort to
expedite this verification requirement, we encourage you to upload
your diploma or transcript at time of application.
In support of our mission to improve health every day, this is a
tobacco-free environment. Associated topics: adjuster, auto,
automobile, bodily, insurance, insurance adjuster, insurance
investigator, investigate, investigation, title examiner
Keywords: Sentara Health, North Miami , Claims QA Analyst, Professions , Miami, Florida
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here to apply!
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