City/State
Doral, FLOverview
Work Shift
First (Days) (United States of America)AvMed, a division of Sentara Health Plans in the Florida market, is hiring a Claims QA Analyst in Miami and/or Gainesville, Florida. This is a hybrid position, 2 days in office and 3 days remote.
Scope of position:The Claims QA Analyst conducts audits of AvMed, Delegated Vendors, and Business Process Outsourcing (BPO) claims. The Claims QA Analyst conducts claims audits and works closely with the BPO to identify and correct any audit findings.
Essential Job Functions:
Minimum Requirements:
Preferred Requirements:
Our Benefits:
As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to:
Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Benefits - Sentara (sentaracareers.com)
Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, and growth!
Note: Sentara Healthcare offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.
Keywords: Talroo-Health Plan, #INDEED, Auditing, Claims, Configuration
Job Summary
Expected to work closely with the Manager, other clinical and QI staff to assure the overall success of the Healthcare Effectiveness Data and Information Set (HEDIS) Project, appropriateness of care and other QI Projects as assigned. Primarily responsible for conducting medical record reviews, data entry and abstraction of data for HEDIS measures, appropriateness of care and other quality initiatives to meet regulatory and contractual requirements for the health plan.Qualifications:
BLD - Bachelor's Level Degree: Nursing (Required), MLD - Master's Level Degree: Counseling, MLD - Master's Level Degree: Psychology, MLD - Master's Level Degree: Social WorkDriver's License - Certification - Other/National, Driver License - Certification - North Carolina Division of Motor Vehicles (NCDMV), Driver License - Certification - Virginia Department of Motor Vehicles (VDMV), Licensed Clinical Social Worker (LCSW) - State license - North Carolina Social Work Certification and Licensure Board (NCSWCLB), Licensed Clinical Social Worker (LCSW) - State license - Virginia Department of Health Professionals (VADHP), Licensed Marriage and Family Therapist (LMFT) - State license - North Carolina, Licensed Marriage and Family Therapist (LMFT) - State license - Virginia Department of Health Professionals (VADHP), Licensed Professional Counselor (LPC) - State license - North Carolina, Licensed Professional Counselor (LPC) - State license - Other/National, Licensed Professional Counselor (LPC) - State license - Virginia Department of Health Professionals (VADHP), Registered Nurse (RN) Single State - Nursing License - North Carolina, Registered Nurse (RN) Single State - Nursing License - Virginia Department of Health Professionals (VADHP)ClinicalSkills
Microsoft OfficeSentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.
In support of our mission "to improve health every day," this is a tobacco-free environment.