Position Summary

The Quality Assurance Specialist is responsible for all claims audits and adjustments. This role ensures the department's completeness, accuracy, and objectives while providing efficiency and effectiveness to Operations.

"Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job Description/Role."

Key Duties and Responsibilities

• Assist with the auditing and adjustments of all types of claims.
• Ensure the completion and submission of all required audit reports to management.
• Analyze and identify training needs based on audit results and system issues.
• Skilled in reviewing and adjusting various types of claims.
• Answer phone calls and greet walk-in customers in a friendly, courteous, and professional manner.
• Conduct backup tasks for various claims and customer service positions.
• Identify potential problems or trends in processes and suggest changes for management review.
• Identify potential issues and suggest possible solutions for improving processes.
• Must comply with the department's quality and error ratio guidelines for this job, as outlined in the Production and Error Ratio guidelines.
• Seeks opportunities to deliver the highest quality of service. Actively listens and communicates effectively with participants, colleagues, clients, employers, and vendors.
• Excels in a team environment and requires minimal supervision.
• Provide assistance to participants, co-workers, clients, employers, and vendors in a friendly, courteous, and professional manner.
• Assist with specific projects as needed.
• Performs other duties as assigned.

Minimum Qualifications

• High School Diploma or GED.
• Strong knowledge of interpreting Plan Documents including Eligibility, Exclusions, and Limitations
• Minimum of 1 years of experience as a Claims Examiner, Customer Service Representative (CSR), or in specialized roles within the department.
• Possess a strong understanding of CPT, ICD-9, and HCPCS coding.
• Extensive knowledge of claims processes and customer service systems.
• Must be proficient in Microsoft Word, Excel, and basic database management.
• Skilled in company software, including Contribution Accounting System, Encounter Tracking, Claims System, and Electronic Reference.

*Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee of this job. Duties, responsibilities and activities may change at any time with or without notice.

Working Conditions/Physical Effort

• Prolonged periods of sitting at a desk and working on a computer.
• Normal degree of physical effort in typical office environment with comfortable, constant temperatures and absence of objectionable elements.
• May be subject to interruptions.
• Must be able to have flexible work schedule when workflow requires.
• Meets established attendance and punctuality guidelines.
• Must be able to lift 15-25 pounds at times.

Disability Accommodation

Consistent with the Americans with Disabilities Act (ADA) and other applicable federal and state law, it is the policy of Zenith American Solutions to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Recruiting Department at recruiting@zenith-american.com, and we would be happy to assist you.

Zenith American Solutions

Real People. Real Solutions. National Reach. Local Expertise.

We are currently looking for a dedicated, energetic employee with the necessary skills, initiative, and personality, along with the desire to get the most out of their working life, to help us be our best every day.

Zenith American Solutions is the largest independent Third Party Administrator in the United States and currently operates over 44 offices nationwide. The original entity of Zenith American has been in business since 1944. Our company was formed as the result of a merger between Zenith Administrators and American Benefit Plan Administrators in 2011. By combining resources, best practices and scale, the new organization is even stronger and better than before.

We believe the best way to realize our better systems for better service philosophy is to hire the best employees. We're always looking for talented individuals who share our dedication to high-quality work, exceptional service and mutual respect. If you're interested in working in an environment where people - employees and clients - really matter, consider bringing your talents to Zenith American!

We realize the importance a comprehensive benefits program to our employees and their families. As part of our total compensation package, we offer an array of benefits including health, vision, and dental coverage, a retirement savings 401(k) plan with company match, paid time off (PTO), great opportunities for growth, and much, much more!