$ads={1}
You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.
DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.
Job Description:
**Candidate must live in Oklahoma
- Performs routine and focus audits on claim processing staff and auto-adjudicated claims to identify inaccurate claims adjudication.
- Assess accuracy and consistency of claims processed for each claims processor and random sampling of auto-adjudicated claims.
- Identify prevalent trends to management.
- Provide quality feedback to individual claims processors and to Supervisor through error reporting process.
- Collaborate with other Claims staff and leadership team on the use of established business processes, procedures and related tools.
- Work with claims leadership team to identify, develop, and implement business processes and tools used by staff to improve claim accuracy results.
- Work with claim processing staff to resolve difficult or complex claims, and recommend related training opportunities that will improve claim payment results.
- Work with the Claims staff and leadership team to develop and implement new or revised business processes as required by the enterprise wide project office or compliance team (regulatory changes.)
- Demonstrate proficiency with the principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approach.
- Adhere to Interrater Reliability principles to ensure the audit results generated meet the accepted criteria by quantitatively defining the degree of agreement between two or more auditors.
- Develop and coordinate the implementation of systems, procedures and forms to improve data collection.
- Assist in the development of action plans to address quality deficiencies.
- Assist in facilitating new hire training as it relates to "Quality".
- Develop and update quality templates and Access SQL Database with current audit review elements.
Reporting:
- Produce weekly, monthly, quarterly and annual management and operations focused reports.
- Assist in developing and maintaining dashboard to report Corporate and Client Quality results.
JOB REQUIREMENTS:
- Two to four year College Degree in Finance or Healthcare preferred. High School diploma/GED Required.
- 2 or more years of Claims Processing experience in health care industry, preferably in an auditing role.
- Ability to analyze, interpret and apply business and operational policies and procedures for prompt and accurate claims payment.
- A thorough understanding of dependents, relationship types and eligibility guidelines to ensure consistency in validation of plan participation.
- Demonstrated excellence in data gathering, analysis, reporting and process improvements.
- Ability to make sound decisions.
- Ability to analyze and solve problems.
- Strong interpersonal, written and oral communication skills.
- Proven logic and reasoning skills that apply methods of consistency, validity, soundness and completeness.
- In depth knowledge of Windward a plus.
- Strong computer skills. Intermediate to Advanced knowledge of Microsoft Excel and Word required.
- Ability to work overtime as needed or required.
PHYSICAL DEMANDS:
- Position is based on-site at our Grafton, Wisconsin location.
- Requires the effective use of all office equipment including, but not limited to, telephone, computers, printers, and fax machines.
- Ability to sit in front of computer terminal for extended periods of time.
- The Quality Assurance area is located in a wheelchair accessible building. The office environment is active with high voice levels and interruptions that may challenge hearing and concentration.
Our Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email recruitingUS@sunlife.com to request an accommodation.
At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.
For applicants residing in California, please read our employee California Privacy Policy and Notice.
Job Category:
Posting End Date:
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran
