Quality Assurance - Specialist 2, PCU
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AI Summary
Perform quality reviews of LTC insurance operational and claim transactions to ensure accuracy and adherence to standard operating procedures. Responsible for reviewing benefit eligibility, documenting errors, and reporting quality results to management and clients.
This job performs quality review for the LTC Insurance operational and claim environment by primarily reviewing processed transactions for accuracy. This includes, but is not limited, to the following essential duties and responsibilities:
Duties/Responsibilities:
· Review all policy administration and claim level transactions against the standard operating procedures.
· Maintain the review of all Daily and Monthly billing suspense items.
· Responsible for reviewing benefit eligibility determinations to ensure that the claim recommendations meet the contractual obligations of the policy.
· Assign and document all mechanical and financial errors as discovered.
· Maintains a strong working knowledge base of all Long-Term care products and services.
· Maintain production and quality standards established in the department.
· Participate and support policy review decisions in the appeal process.
· Monthly reporting to all engagement managers and supervisory staff on the quality results of their department and staff
· Participate in client level meetings. Create action plans as agreed upon with the client and meet all timelines and deliverables.
· Complying with company regulations regarding HIPAA, confidentiality, and private health information.
· Other duties may be assigned.
· Ability and Flexibility to work overtime as required.
Required Skills/Abilities:
· In-depth insurance knowledge. Focus on Long Term Care Insurance and Benefit Eligibility determinations a plus.
· Promote an exceptional level of excellence and pride in Customer Service
· Integrity/Honesty
· Sound interpersonal and communication skills
· Motivation
· Ability to multi-task
· Meticulous attention to detail
· Ability to lead others through performance and professionalism.
· Ability to work in a fast-paced environment.
· Highly developed problem-solving skills.
· Organizational/Planning/Organizing
· Proficiency in basic computer applications is required. (MS Word, MS Excel
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