Claims Quality Auditor- Hybrid
Company: Parkland Health and Hospital System (PHHS)
Posted on: February 10, 2024
Interested in a career with both meaning and growth? Whether
your abilities are in direct patient care or one of the many other
areas of healthcare administration and support, everyone at
Parkland works together to fulfill our mission: the health and
well-being of individuals and communities entrusted to our care. By
joining Parkland, you become part of a diverse healthcare legacy
that's served our community for more than 125 years. Put your
skills to work with us, seek opportunities to learn and join a
talented team where patient care is more than a job. It's our
passion.Primary PurposeReviews, analyzes, and adjudicates
professional claims, claim appeals, corrected claims and refunds
from UTSW for physician services performed on Parkland unfunded
patients, to ensure accurate records and disposition of claims in
accordance with contractual business rules. Performs claims data
analysis and presents results and recommendations to the department
- Bachelor's degree in health or finance-related field is
- Must have five years of experience in accounting, business
office, or medical insurance claims environment, in a large volume
- Must have experience with Medicare billing/reimbursement rules
- Must have experience in large data management.
- Must have experience with Texas Medicaid program eligibility
- Must have knowledge of ICD10, CPT physician coding/billing
operations, and medical terminology.
- Prefer experience with EPIC software.
- Prefer experience in SQL (Crystal Reports) report
writing.Equivalent Education and/or Experience
- May have an equivalent experience in lieu of specific
education.Skills or Special Abilities
- Must understand managed care and government payers'
reimbursement principles, billing and claim adjudication
- Must be able to observe emerging trends and track them using
analytics and critical thinking methods.
- Must have a demonstrated ability to develop clean, insightful,
and easily digestible potential financial impact and claims
- Must be able to conduct financial reconciliation projects using
logic, revenue cycle and professional billing/claim adjudication
knowledge with criteria and data elements provided.
- Must be able to demonstrate expertise with SQL reporting
(example: Crystal Reports). Must be able to prepare detailed and
summary reports and charts.
- Must have expert level skills in Microsoft software, including
Word, Excel, Access, PowerPoint, Outlook, and Visio.
- Skilled with the ability to receive strategic direction and
execute with minimal supervision
- Must be detail oriented, organized, and possess strong
analytical and mathematical skills to ensure accurate and timely
processing of accounting records and resolve complex accounting
- Must demonstrate ability to meet deadlines while balancing
- Must demonstrate ability to identify and research data
- Must be able to solve problems within the guidelines of
established policies and procedures.
- Must be able to communicate effectively with internal and
external customers. Must be customer service oriented.
- Must have experience with project management
- Analyzes, documents, and adjudicates monthly claims data,
appeals, corrected claims and refunds for professional clinical
services for Parkland covered patients.
- Performs a detailed quality assurance of claims processed by
the Third-Party Administrator (TPA). Generates patient eligibility
and coverage reporting from EPIC and validates patient's unfunded
- Provides data management support and creates custom reports to
illustrate claim adjudication trends and issues for administration.
Implements recommended revisions to process or TPA system set up as
needed, to streamline claim, appeals and refunds adjudication.
- Identifies trends in TPA errors that have resulted in appeal
claims. Reports those trends to Manager of Department Systems and
assists with corrective measures with the TPA or UT Southwestern
- Collects and aggregates claims data, translates business
questions from the leadership team and translates them into
analytical solutions. Presents analysis results/recommendations to
the leaders in a timely, consistent, and accurate manner.
- Provides revenue reporting and data extracts for an annual
Divisional Guarantees reconciliation process.
- Collaborates with internal IT and external TPA vendor to ensure
adherence to the UT Contract business rules of adjudication. Works
to ensure annual updates and modifications to the business rules
- Work with large data for ad hoc reporting and trend analysis
for UT Contracts Team.
- Validates denial reasons and ensures coding is accurate and
reflects the denial reasons. Coordinates with the Nurse Auditor for
clinical consultations or account referrals when necessary.
- Provides guidance and support to all UT Contracts personnel
toward resolution of claim-related issues with an emphasis on
root-cause analysis and problem resolution.Job
- Identifies ways to improve work processes and improve customer
satisfaction. Makes recommendations to supervisor, implements, and
monitors results as appropriate in support of the overall goals of
the department and Parkland.
- Stays abreast of the latest developments, advancements, and
trends in the field by attending seminars/workshops, reading
professional journals, actively participating in professional
organizations, and/or maintaining certification or licensure.
Integrates knowledge gained into current work practices.
- Maintains knowledge of applicable rules, regulations, policies,
laws, and guidelines that impact the area. Develops effective
internal controls designed to promote adherence with applicable
laws, accreditation agency requirements, and federal, state, and
private health plans. Seeks advice and guidance as needed to ensure
proper understanding.Parkland Health and Hospital System prohibits
discrimination based on age (40 or over), race, color, religion,
sex (including pregnancy), sexual orientation, gender identity,
gender expression, genetic information, disability, national
origin, marital status, political belief, or veteran status.As part
of our commitment to our patients and employees' wellness, Parkland
Health is a tobacco and smoke-free campus.
Keywords: Parkland Health and Hospital System (PHHS), Dallas , Claims Quality Auditor- Hybrid, Accounting, Auditing , Dallas, Texas
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