• Claims Quality Control Representative

    Job Locations US-RI-Smithfield
    Req No.
    Regular Full-Time
  • Overview

    Under the general supervision this position ensures that claims are processed accurately according to the company’s contractual obligations and applicable regulatory guidelines. He/she provides feedback on training needs for the claims staff based on identified issues.


    • Perform quality control of claims adjudication to ensure accurate payments based on member eligibility, benefits and policy & procedures
    • Responsible for monitoring and assessing the quality of inbound provider calls for all lines of business
    • Prepare and maintain written reports of findings for all QC activity performed for internal tracking and possible external regulatory agencies
    • Communicate all issues to individual staff members when possible via verbal or written communication
    • Collaborate with trainers and claims management regarding necessary training for staff based on QC findings
    • Recommends improvements to department procedural guidelines
    • Recommends or notifies claims management of identified system issues
    • Other duties as assigned
    • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents



    • High school graduate or equivalent
    • Current certificate as a Professional Coder
    • Three (3)+ years’ experience in all aspects of physician and facility
    • Minimum Three (3) years’ direct application of coding, billing and reimbursement mechanisms
    • Experience with all aspects of claims department operations, specifically claims processing
    • Demonstrated decision making skills
    • Strong verbal and written communications skills
    • Excellent customer service skills
    • Strong interpersonal skills
    • Ability to effectively prioritize and execute tasks in a high-pressure environment is crucial
    • Mathematical skills and detail accuracy
    • Computer literate in Microsoft Office
    • Able to work efficiently in both a team atmosphere as well as independently


    • Knowledge of COGNOS reporting environment
    • Minimum of three years of experience in all aspects of physician and facility

    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.


    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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