Senior BPM Associate (Claims QA)

Role Description

The QA Associate is responsible for conducting thorough and accurate reviews and audits of medical claims in accordance with established claims guidelines and policies.

Responsibilities

• Review claims or update existing claims by taking the appropriate and necessary actions as defined by guidelines
• Analyze claims to determine the appropriate course of action, approving or denying actions taken by agents as required
• Ensure that correct payment criteria have been applied for clearing pending claims, based on defined organizational policies and procedures
• Research claim edits to verify if the proper application of benefits has been made, including the use of established criteria and, when relevant, the application of physician contract pricing for entry-level claims processed by claims processors
• Review and confirm that provider inquiries related to claim adjudication have been properly address...