Paramount Health Care, a ProMedica Health Plan, offers insurance products across six Midwest states. This Ohio-based company, headquartered in Toledo, has more than 685 employees dedicated to serving their health plan members.

Paramount offers Medicare Advantage and Marketplace Exchange health plans for individuals and families. Paramount maintains accreditation by the National Committee for Quality Assurance (NCQA) for their HMO and Medicare Advantage products.

In addition, Paramount has a full complement of insurance products for employers of any size, including medical, dental, vision and workers’ compensation, as well as vocational rehabilitation, life-care planning and wellness.

As a part of ProMedica, Paramount is driven by ProMedica’s mission to improve your health and well-being. ProMedica has been nationally recognized for its advocacy programs and efforts to address social determinants of health. Paramount strives to provide an exceptional experience to every member. For more information about Paramount, please visit our website at paramounthealthcare.com.

Basic Purpose:

Perform quality assurance functions as they pertain to claims transactions audits by means of identifying, documenting, and communicating information. The Claims QA Auditor maintains, and provides statistical reports to claims management as requested. Works cooperatively with the claims trainer and claims team leaders to propose and implement solutions to always provide the best outcomes for our groups, members, and providers. Supports activities related to internal/external audits to ensure timely dissemination of requested information/materials.

No positions report directly to this position.

Primary Duties:

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  Perform quality reviews as outlined in department procedure CP-194 on a random sample of claims to ensure internal department standards, third party payer, and governmental requirements are met for QA standards.
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  Disseminate QA information/findings to claims staff in a timely manner using the current agreed upon process outlined (e.g., via email) in a clear and professional manner.
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  Work with claims trainer to identify, document, and propose solutions for areas of variations from the norm, or potential high-risk areas requiring further one-on-one or group training.
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  Maintain worksheets that support the overall details of the QA program within the claims department.
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  Provide the Director of Claims and team leaders with timely detailed monthly reports that outline departmental and individual statistical results as requested.
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  Support the claims department by reviewing procedural documentation on claims processing as they relate to QA reviews. Provide recommendations based on findings.
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  Support Sr. Auditor with external claims audits for employer audit, governmental agencies or as assigned in a timely and efficient manner by assembling materials, preparing agenda, printing system reports and providing appropriate documents for review.
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  Perform other duties as directed to support claims functions, which are focused on achieving both departmental and organizational objectives.

General Information/Qualifications:

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  Associates degree in Finance/auditing strongly preferred
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  Minimum five years of experience with claims processing and adjustments, COB, and payment refunds for all lines of business and all types of claims required.
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  Spreadsheet and database skills required. Demonstrated Excel at least level 2
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  Excellent written, verbal, and interpersonal communication skills required
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  Quality assurance program experience highly desirable
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  Experience or strong working knowledge of benefit/pricing configuration, provider database maintenance, or related configuration experience desired.
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  Good working knowledge of HCFA, State of Ohio and Michigan compliance regulations, and institutional/professional ECS submission formats highly desirable.
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  Demonstrated ability to handle detail and maintain confidential information.
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  Ability to prioritize and handle large volumes of work.
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  Ability to work in a production environment that can be stressful.
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  Maintain a high level of motivation, initiative, and accountability.
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  Ability to work independently; plan, coordinate, and organize multiple priorities.
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  Ability to operate general office equipment; ability to communicate on telephones and move between company work stations.

ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org

Equal Opportunity Employer/Drug-Free Workplace