Claims & Quality Analyst

POSITION SUMMARY:

The Administrative Claims and Quality Analyst is responsible for assisting in the day-to-day functioning of the MHW Quality/ Claims Department, maintaining the integrity of the eligibility/authorization database, completing the weekly claims and check run process, the self-directed payroll and compiling reports. This position will represent ABH and its services in a positive and professional manner and adhere to ABH’s best practices, guidelines, policies and procedures as established, promoting ABH as a leader in behavioral healthcare in all interactions and work.

DUTIES AND RESPONSIBILITIES:

• Interacts with providers and office staff to answer routine inquiries related to the MHW eligibility, authorization and claims process. This responsibility includes but is not limited to: an understanding of the eligibility, authorization and claims processes and how they relate to the Mental Health Waiver. 
• Coordinates with DSS, DHMAS, Gainwell Technologies and Sandata staff and maintains a comprehensive knowledge of Mental Health Waiver services with regard to benefits, eligibility, network and referral options, and an understanding of Explanation of Benefit forms, Provider Remittances, Communication forms and the reimbursement process;
• Interacts with Care Managers and Providers to answer MHW related questions;
• Creates new client records by adding eligibility and disposition screens and client demographic information and updating the system as required.
• Completes the weekly payroll for the Self-directed Recovery Assistants;
• Adds new claims, performs the weekly claims audit, uploads and downloads claims files and performs the bi-weekly check run.
• Maintains knowledge of procedure (CPT) and diagnostic (ICD-10-CM) codes, medical and behavioral health insurance terminology;
• Assists with the monthly Eligibility verification, the Provider/Client Surveys and the Monthly notes process;
• Observes policies and procedures related to confidentiality of medical records, release of information and retention of records;
• Monitors, identifies and reports problems of potential unethical conduct, fraud and/or abuse to QA Supervisor
• Employs interpersonal expertise to provide good working relationships with members, providers, facilities and other ABH personnel;
• Maintains confidentiality of all client protected health information and adheres to all HIPAA related policies and procedures;
• Performs other tasks/responsibilities as required to support the business operations;
• Demonstrates ethical behavior and cultural sensitivity in all activities involving individuals of diverse backgrounds;
• Other duties as assigned;

Requirements

EDUCATION AND EXPERIENCE REQUIREMENTS:

• Associate degree required or equivalent combination of education, experience and training that provides the required knowledge skills and abilities;
• 1-3 years of demonstrated work experience in an administrative assistant or related position;

KNOWLEDGE/SKILLS/ABILITIES:

• Willingness to develop an in-depth knowledge of the WISE online system created by ABH and used by all MHW staff;
• Working knowledge of EVV (Electronic Visit Verification) Process
• Must be flexible in order to respond quickly and positively to shifting demands;
• Strong attention to detail; ability to work on multiple tasks and meet deadlines;
• Excellent PC skills with demonstrated experience using Microsoft Office Package (MS Word, Excel and Outlook);
• Strong written and verbal communication skills required;
• Excellent communication skills needed, and the ability to continually prioritize needs of staff and providers.