Delegation Oversight Claims Auditor

Location: Remote-US, California US

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Job Number: 4771

Position Title: Claims Delegation Oversight Auditor

External Description:

 

The Delegation Oversight Claims Auditor (DOAC) reports directly to the Claims Delegation Oversight Manager (CDOM). Plans and conducts audits of Alignment’s contracted entities delegated for Medicare Advantage claims processing. Promote and maintain a positive working partnership with the delegated entities. Ensure adherence of Federal and/or State claims requirements, and other claims standards. Coordinates and leads all delegated claims audits.

 

General Duties/Responsibilities (May include but are not limited to):

  • Conduct annual risk assessment of delegated entities; develop the delegated entity claims annual audit plan
  • Schedule and maintain the claims audit schedule
  • Conduct audit of case file samples and other supporting documentation against CMS, claims processing standards, and other established criteria
  • Analyze audit results and produce a complete and concise audit report
  • Issue corrective action requests where required
  • Ensure corrective action plan responses are properly developed and follow-up items are completed according to agreed-upon deadlines.
  • Conduct validation audits as needed.
  • Review audit finding trends to identify training opportunities; collaborate with the DO Manager to draft training documents for distribution
  • Create and maintain accurate, complete, and current audit records
  • Participate in CMS and/or other regulatory audits as needed

Supervisory responsibilities:

N/A

 

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

· Minimum Experience:

a. 5 + years of claims processing or claim management experience in a Medicare Advantage Health Plan or Medical Group/IPA setting.

b. 2 + years experience in a delegation oversight role in a Medicare Advantage Health Plan.

c. Possess in-depth knowledge of managed care operations, with emphasis on claims processing functions.

d. Comprehensive knowledge and experience with CMS compliance reporting, i.e., Part C ODR, ODAG, Monthly Timeliness, etc.

· Education/Licensure:

a. Requires a high school diploma (Associate or bachelor’s degree in a related area is preferred)

· Other:

a. Knowledge of Medicare Advantage audit processes and applicable state and federal regulations.

b. Must possess a high level of organization skills to maintain accurate records and documentation.

c. Attention to detail with analytical and problem-solving capabilities

d. Ability to take initiative and see tasks to completion

e. Excellent verbal and written communication skills

f. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPPA) regulations

g. Ability to establish and maintain positive and effective work relationships with

delegated entities.

h. Ability to scope and identify potential issues and escalate accordingly

i. Mathematical Skills: Ability to calculate figures and amounts such as discounts, interest, proportions and percentages. Ability to apply concepts of basic algebra.

j. Excellent computer skills with a strong proficiency in Excel, Word, SharePoint, PowerPoint.

k. Other Skills and Abilities:

i. Excellent verbal and written skills

ii. Knowledge of medical terminology

iii. Familiarity with various claims processing systems is a plus

iv. Knowledge of claims coding, CPT, ICD-10, HCPCS or other coding

v. Strong knowledge of CMS, Federal and State regulatory claims requirements

City: Remote-US

State: California

Location City: Remote-US

Location State: California

Community / Marketing Title: Delegation Oversight Claims Auditor

Company Profile:

Alignment Health was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time.

By becoming a part of the Alignment Health team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community.

EEO Employer Verbiage:

Alignment requires all new hires to follow local and/or state requirements regarding the COVID-19 vaccine and booster.  If applicable, proof of vaccination and booster will be required as a condition of employment subject to legal exemptions.  This policy, which Alignment reserves the right to modify, is part of Alignment’s ongoing efforts to ensure the safety and well-being of its staff and community and to support public health efforts.

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.

If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact [email protected].

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].