Audits & Quality Assurance Coordinator is responsible for insurance audit requests and appeals processing, post service review of patient’s medical records and customer care team member’s transactions and productivity to ensure proper processing of orders. He/She will be also responsible for preparing, drafting and submitting responses to various departments, management teams or auditing agencies on matters of compliance, quality adherence and medical review.

Key Responsibilities:

• Insurance Audit Request Processing
  • Handles correspondence pertaining to requests of medical documentation from all insurance, government, and commercial auditing agencies
  • Logs audit request on a spreadsheet in the shared folder
  • Reviews billing history and notes of the audited equipment or accessories in HDMS (Billing Software)
  • Pulls all requested medical documentation (Rx/Certificate of Medical Necessity (CMN), Chart Notes, Lab Results, Proof of Delivery, etc.) from DocFlow (Document Management Software)
  • Reviews medical documentation and identify missing elements per insurance requirements
  • Requests and follow up additional documentation or missing elements from doctor’s offices, hospitals, customer care, medical necessity, and/or accounts receivable teams
  • Communicates to auditing agencies if clarification or additional information is required
  • Creates cover letter with summary of patient’s qualifying medical condition
  • Compiles all medical documentation into one PDF file format
  • Submits medical documentation to auditing agencies via fax or insurance portals

• Insurance Appeals Processing
  • Handles all correspondence pertaining to audit decisions from insurance, government, and commercial auditing agencies
  • Logs audit decision on a spreadsheet in the shared folder
  • Requests and follow up additional documentation or missing elements identified during audit from doctor’s offices, hospitals, customer care, medical necessity and/or accounts receivable teams
  • Creates cover letter & compiles all medical documentation for all levels of appeal into one PDF file format
  • Communicates decision to accounts receivable team on whether to continue to bill or pick up the equipment
• Performs daily quality assurance audit of customer care team members
• Provides daily & weekly productivity and quality assurance reports to customer care teams
• Attends all departmental meetings, company meetings, and in-services
• Understand and adheres to all of company policies
• Maintain a professional safe and clean work environment
• All other appropriate tasks identified and assigned by the Audits & Quality Assurance Manager

• Candidate must possess at least a Bachelor’s Degree in Medical related course
• At least 1 year of working experience in the related field (Experience in working for healthcare, medical, or home medical equipment/pharmacy industry or experience in medical billing and/or medical coding or general knowledge of Medicare and/or commercial insurance general billing guidelines)
• Demonstrated ability to review patient medical records and determine morbidities, limitations and needs
• Effective written and verbal English communication skills
• Amenable to work in Mall of Asia site