Under the general supervision of the Director of Managed Care and Network Operations, the Compliance Claims Auditor works in conjunction with the Claims Manager to prepare all required documents and reports for Federal, State and Health Plan audits. The Compliance Claims Auditor is responsible for all preparation, presentation, submission and response to Federal, State and Health Plans regarding all auditing requests. The Compliance Claims Auditor will work with the Director of Managed Care and Network Operations to prepare and submit, monitor and respond to all Corrective Action Plans (CAP). The Compliance Claims Auditor will also be responsible for generating Claims Department Monthly, Quarterly, and Annual reports for the Claims Department and for assuring the accuracy and timeliness of those reports. In addition to these responsibilities, the Claims Compliance Auditor will assist the Claims Manager to assure the system has been updated regarding provider pricing, benefit management, etc. The Claims Compliance Auditor will be responsible for report generation from the IT system relative to all reports necessary for MSO reporting. Interacts with a multi-cultural population of diverse socioeconomic backgrounds, levels of education and ages.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES
The Compliance Claims Auditor is responsible for performing the following duties:
- Responsible for generating all reports in claims system requested by management to fulfill data analysis.
- Responsible for generating all required reporting from health plans including ODAG and Monthly Timeliness Reports (MTR), and from State or Federal regulatory agencies.
- Works within claims system to define the Plan parameters for use in selecting electronic claims data within the audit criteria.
- Reviews Audit Reporting, selects and prepares valid audit samples following the standard departmental process.
- Works with Claims Manager to resolve exceptions, reviews supporting documentation and makes final claim error determinations.
- Ensures compliance with audit timelines and delivers high quality service to clients, governmental agencies and/or Health Plans.
- Works with the Director of Managed Care and Network Operations to prepare and submit, monitor and respond to all Corrective Action Plans (CAP).
- Prepares or assists in preparing audit reports that clearly articulate the audit methodology and content. Prepares work papers that support audit reports. Keeps audit history and documentation for all audits.
- Provides support-prepping reports such as, but not limited to, quality assurance on system reporting and audit reports, sample selection, etc.
- Prepares responses for all corrective actions as well as identifies areas for potential process improvement to the client and claims manager.
- Interacts in a professional manner and works collaboratively within the department as well as with internal and external customers.
- Participates in team meetings, conference calls, WebEx’s, etc. remotely / locally as necessary.
- Responsible for Claims Data Analysis and Quality Assurance as requested.
- Supports the department with all external audit management and contractual reporting.
- Remains current with all State, Federal and health plan regulatory and ICE requirements for auditing compliance for all payers.
- Perform other duties as assigned including participation in all safety programs that may include assignment to an emergency response team.
This is an excellent opportunity to work for an organization that truly makes a difference in the community. Clinicas Del Camino Real, Inc. offers a highly competitive salary; excellent benefit package including full medical, dental, vision, life and disability insurance; generous holiday, vacation and sick leave.
- High school diploma or equivalent is required. Associate’s degree is preferred.
- 3-5 years of experience in claim adjudication from a major insurance claims administrator or health plan environment
- Previous Auditing /QA experience
- Proficient in the use of Microsoft Office Software (i.e., Word, Excel, PowerPoint)
- In-depth knowledge of ICD-10, CPT, HCPCS, revenue codes and medical terminology
- Knowledge of CMS rules and regulations as well as DMHC and DHCS requirements.
- Must demonstrate a high level and familiarity of claims administration, including experience with medical, dental, mental health, prescription, Medicare, Medi-Cal, and Commercial claims adjudication.
- Proficient with healthcare claim adjudication standards and procedures, including application of benefit plan designs, administrative services agreements, coordination of benefits and subrogation provisions.
- Strong organizational skills and the ability to efficiently prioritize multiple tasks
- Excellent oral and written skills required
- Self-directed individual who requires little supervision and can work effectively independently or in a team setting
- Team player with a strong work ethic