Claims Quality Control Specialist III

HMA is the premier third-party health plan administrator across the PNW and beyond. We relentlessly deliver on our promise to provide medium to large-size employers with customized health plans. We offer various high-quality, affordable healthcare plan options supported with best-in-class customer service.
We are proud to say that for three years, HMA has been chosen as a 'Washington's Best Workplaces' by our Staff and PSBJ™. Our vision, 'Proving What's Possible in Healthcare™,' and our values, People First!, Be Extraordinary, Work Courageously, Own It, and Win Together, shape our culture, influence our decisions, and drive our results.
What we are looking for: We are always searching for unique people to add to our team. We only hire people that care deeply about others, thrive in evolving environments, gain satisfaction from being part of a team, are motivated by tackling complex challenges, are courageous enough to share ideas, action-oriented, resilient, and results-driven.
What you can expect: You can expect an inclusive, flexible, and fun culture, comprehensive salary, pay transparency, benefits, and time off package with plenty of personal development and growth opportunities. If you are looking for meaningful work, a clear purpose, high standards, work/life balance, and the ability to contribute to something important, find out more about us at: https://www.accesshma.com/
How YOU will make a Difference:
The Quality Control Specialist will help ensure that accurate processing has been applied to plan documentation, enrollment eligibility data and claims prior to payments being issued. You will be essential in ensuring that proper pricing and benefit applications have been applied to the claim to protect members from unnecessary financial burden, and to guarantee the employer is paying the correct amount for medical services.
What YOU will do:

• Perform daily quality audits on a subset of processed claims that are standard local claims.
• Perform daily quality audits on a limited subset of processed claims for Regence pricing verification.
• Perform high dollar audits on claims $75,000.
• Manage daily personal inventory to ensure overall audit inventory is within acceptable control levels.
• Prioritize and assist with urgent audit requests
• Deliver daily reporting and distribution on Group Notifications for high dollar claims.
• Perform Group setup in SharePoint.
• Perform daily quality audits for specialty claims; Kidney Dialysis, Transplant, Air Ambulance, Federal NSA, etc.
• Support as a subject expert BPO partners for daily queries and process questions.
• Perform quality audits and support external 3 rd party Client audits as an audit driver and subject expert.
• Perform BCBSA LDLA Home Plan Auditing and final audit sign-off.
• Perform the review and updates of process documentation for all Claims Teams.
• Provide support as subject expert for Claims and Quality related projects and Client plan intent.
• Trainer and subject expert for:

1. Pricing Audits.
2. Trainer and subject expert for all BCBSA Host Plan claims.
3. Trainer and subject expert for all high dollar claim audits, specialty claim audits.
4. Trainer and subject expert for BCBSA LDLA Home Plan process and auditing.

Knowledge, Experience, and Key Attributes needed for Success:

• High School Diploma required; AA degree preferred
• Certified Quality Auditor certification required
• 5-7 years of related quality experience required
• Prior experience in healthcare required
• Strong interpersonal and communication skills
• Strong attention to detail, with high degree of accuracy and urgency
• Ability to take initiative and ownership of assigned tasks, working independently with minimal supervision

Compensation The base salary range for this position in the greater Seattle area is $30.76/hr - $39.90/hr for a level IIII and varies dependent on geography, skills, experience, education, and other job or market-related factors. While we are looking for level I, we may consider level II for highly qualified candidates. In addition, HMA provides a generous total rewards package for full-time employees that includes: seventeen (IC) days paid time off; eleven paid holidays, one paid personal and one paid volunteer day; company-subsidized medical, dental, vision, and prescription insurance; company-paid disability, life, and AD&D insurances; voluntary life insurances; HSA and FSA pre-tax programs; 401(k)-retirement plan with company match; wellness incentive and reimbursement; remote work and continuing education reimbursements; discount program; parental leave; and a charitable giving match. For more information about HMA, visit www.accesshma.com .
Disclaimer: The salary, other compensation, and benefits information are accurate as of this posting date. HMA reserves the right to modify this information at any time, subject to applicable law.
How we Support your Work, Life, and Wellness Goals
We offer a comprehensive total rewards package including: competitive pay; annual incentive; wellness programs; medical, dental, and vision insurance; 401K retirement plan with match; generous PTO and holidays; an onsite gym; life, AD&D, short and long-term disability insurances; an Employee Assistance Plan with additional mental health support; free parking and easy freeway access to I-405 and I-520; a stocked kitchen on-site with subsidized snacks and refreshments; year-round wellness activities; monthly events; paid volunteer hours and more!
HMA is primarily a remote workforce, requires a reliable internet connection, and provides all hardware. Some roles are required onsite 1-3 days per week/month while other roles are 100% remote.
A background screen prior to employment is required.
Protected Health Information (PHI) Access Healthcare Management Administrators (HMA) employees may encounter protected health information (PHI) in the regular course of their work. All PHI shall be used and disclosed on a need-to-know-basis and according to HMA's standard policies and procedures.
HMA is an Equal Opportunity Employer