Lead, Clinical Quality (Job ID: 838)

Posted: 07/11/17 | SHARE:


Provides feedback to the unit supervisor concerning the daily activities of the unit, ensuring that each unit is running effectively, and handling of priority issues and claim projects is being completed in a timely manner. Acts as point person for the unit, and is responsible for receiving and responding to E-mail, internal and corporate service forms, phone inquiries from ASO Employer group contacts, Member Services, Provider Relations, and all applicable Regional offices. Monitors and assists with the distribution of CSF’s, ISF’s, and E-mail correspondence for claim corrections to the claims examiners for processing. Responsible for reporting functions on a daily, weekly and monthly schedule. These include: Weekly distribution of Disenrollment and Redline distribution; calculating daily production goals for the unit; reviewing of aged claim and correspondence reports to ensure claims do not reach specified age categories. Runs reports showing the daily production numbers of each examiner in the unit; monitors aging of CSF and ISF’s; Calculates and produces the weekly and monthly unit production reports; Reviews high priority reports, requests from ASO Administration and ASO Claims Supervisor, including claim adjudication; analyzes claims processing trends and issues and creates reports from Facets system when needed. Responsible for coordinating specialized training of new and existing claims examiners, as well as forwarding and explaining new claim procedures, processes, and information to each examiner. Works closely with the Operations Department Quality and Training Development Unit to ensure quality control standards and performance guarantee requirements are met and provides regular feedback to each examiner on the accuracy of their work. Reviews quality control appeals and makes first line decisions regarding the outcome of appeals. Keeps Supervisor informed about any system configuration issues, potential employer group benefit concerns and/or issues that may impact the performance guarantees as well as the overall turnaround time and performance of the ASO Key Accounts. The senior will also actively participate in ASO Group audits and presentations as needed and will be involved in stop-loss procedures, policies and inquiries. Performs other duties as assigned.


Minimum Education:
Associate's degree preferred

Minimum Experience: 

Two years’ experience processing health insurance claims required.

Required Skills: 

• Strong interpersonal and presentation skills
• Strong written and verbal communication skills
• Excellent organizational skills and attention to detail
• Proficient in the use of Microsoft Word and Excel.

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