Claim Associate

This position will be responsible for auditing the work within the Organization. As a

member of the Quality Audit Team, the incumbent will have the ability and be

expected to drive change, and positively impact the accuracy and efficiency of operations.

Responsibilities

Completes audits to ensure claim advocates understanding of current policies

and procedures, including job aids, Articles, and alerts. This includes claim

processing guidelines, regulatory requirements, contractual benefits, and specific

customer circumstances.

Understanding of the appropriate application of claim and other directional

documents/tools is a key component of the quality assurance auditing process.

Interfaces with matrix partners in relation to quality audit process, specifically address

gaps identified through audit process and recommendations for gap closure.

Completes review of documents related to audits to help ensure direction is clear and

consistent with processing of work. Provides feedback to operations where updates

may be required to drive consistency and accuracy.

Completes inter-rater reliability exercises with peers, other quality roles and business

owners to provide insight into review process.

Understanding of the appropriate standard operating procedures and other

directional documents/tools is a key component of the quality assurance auditing

process.

Excellent skills in navigation and use of all applications related to Diamond claim role

including but not limited to: Diamond, SAM3, Outlook, CPF, Network X-Pricer,

Salesforce, I Provider, Envoy, Facets, Visium, X-Net, Knowledge Xchange, PIMS

(SANP), etc.

Provides a quality review voice in various workgroups pertaining to workflows,

documentation and issues driving errors, in an attempt to continuously improve

results.

Supports, educates, and reinforces the workflows, processes, tools for the nurses.

Provides support for internal and GSP sites based on business needs.

Support Coaching and Training program and responsibilities when needed to

Support for Business needs and requirements which could include answering Q&A,

facilitate trainings, and Coaching's.

Qualifications

2+ years of overall experience processing claims, with at least 1+ year Diamond

claim processing experience required. US & International claims experience

preferred.

Customer Service Driven; ability to meet and exceed the internal partner and external

customer expectations.

Proven outcomes in critical thinking and decision-making outcomes.

Proven outcomes in problem solving skills; utilization of technical skills and resources

to ensure accuracy of final resolution.

Proven process improvement skills: ability to assess trends, processes, and barriers

to drive positive outcomes for claim resolutions.

Must be comfortable and effective working in a diverse environment; office, and/or

virtual environment.

Strong organization and time management skills; effectively adapts to multiple and/or

competing priorities.

Strong communication skills, both verbal and written; ability to adapt communication

to the individual or audience.