Supervisor, Claims Audit

Job Number: 5279

Workplace Type: Fully Remote

Position Title: Supervisor, Claims Audit

External Description:

The Supervisor of Claims Audit is responsible for the daily supervision of staff performing claims quality review functions. The Supervisor will ensure all staff meet the department’s performance standards.  The Supervisor will assist the Manager of Payment Integrity in ensuring appropriate controls are in place to meet compliance with applicable CMS, state and federal regulations.  

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

·         Monitors department’s performance metrics daily to ensure key performance measures and service levels are met.

·         Monitors claims audit activities which include but are not limited to audit rebuttals, proper documentation, and timely completion of audits.

·         Monitors staff performance (i.e., productivity, quality and attendance). Ensure staff comply with applicable policies and department protocols.

·         Performs root cause analysis, tracks and trends errors to ensure timely and appropriate resolution is established.

·         Collaborates with department management, Configuration and DTS in identifying areas of improvement and participates in process enhancement projects.

·         Assists in the development and maintenance of standard operating procedures (SOPs) and policies and procedures (P&Ps)

·         Assists with training of claims Examiners based on repetitive errors identified month after month.

·         Understands claims and provider dispute and appeals processes to support and provide staff guidance.

·         Provides training, coaching and mentoring to staff members.

·         Submits audit metrics to Management and reports any processing gaps.

·         Facilitates the completion of claim sample documentation for internal and external audit requests.

·         Stays abreast of all regulatory and/or contractual changes and communicates changes to staff.

·         Ensures the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.

·         Fosters good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.).

·         Actively participates in ongoing training to support company and department initiatives.

·         Adheres to all regulatory and company standards, as described in the Employee Handbook and departmental Policies and Procedures.

·         Promotes teamwork and cooperation with other staff members and management.

·         Performs additional related duties as assigned by Management.

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:

o   5+ years medical claims auditing experience in health plan or IPA/Medical Group setting required, preferably Medicare claims.

o   7+ years’ experience in examining all types of medical claims, preferably Medicare claims.

o   3+ years supervisory experience in health plan or IPA/Medical Group setting required.

Education/Licensure:

o   High School Diploma or General Education Development (GED) required.

o   Bachelor’s degree in healthcare management or related field, a plus

Other:

o   Experience working with Provider Dispute and Appeals

o   Proficiency in Microsoft Office programs (Excel, Access, Word), intermediate level

o   Experience using claims processing systems (EZCAP preferred).

o   Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-10, DRG, APC, etc.

o   Working knowledge of different claims payment methodologies and claim editing guidelines.

o   Familiarity with CMS regulations related to Part C claims.

o   Understanding of Division of Financial Responsibility and how it applies to claims processing.

o   Knowledge of claims processing requirements which include but are not limited to eligibility, HMO benefit structures and coordination of benefits.

o   Proven problem-solving skills and ability to translate knowledge to the department.

o   Ability to multitask.

o   Strong organizational skills.

o   Attention to Detail.

 

Work Environment:

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

• While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
• The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Supervisor, Claims Audit

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*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].