Claims Audit Manager

Job Description

POSITION SUMMARY

Strong background on Medi-Cal, Commercial, and Medicare benefits, including coordination of benefits. Works closely with all departments necessary to ensure that processes, programs and services are accomplished in a timely and efficient manner in accordance with AMM policies and procedures and in compliance with applicable state and federal regulations including CMS, MediCal, and DMHC. Claims audit manager ensures incoming claims are processed in accordance with policies, procedures and guidelines, as outlined by AMM and contractual agreements; within mandated timeframes; and according to rate as reflected in respective provider contracts. Manager will be responsible for prepayment, post payment validations and the management of operational reporting, testing and data submissions.

RESPONSIBILITIES-DUTIES

Prepares and coordinates the completion of complex regulatory and compliance reports for submission.

Assists in audit preparations, analyzes information, identifies deficiencies, and tracks corrective action for completion. Processes additional data into the system, ensures that data was processed and researches any interruptions to the process.

Query, analyze, and interpret data for ad hoc analyses.

Apply Medicare Claim Payment rules and requirements, including the application of National Coverage Decisions, Local Coverage Decisions, and National Correct Coding requirements to claims received for payment.

Gather information needed for compliance related activities.

Participates in quality assurance process for all new department related system/application/process changes.

Perform pre-payment audits and post payment audits to validate claims for appropriate coding and documentation and validate accurate claim adjudication rules and fee schedules were applied

Ability to understand, work with and organize data from various systems and databases: facts, figures, narratives, and data analysis.

Demonstrate attention to detail and accuracy in work product. Support all levels of claims staff regarding Medicare Commercial, and Medi-Cal, adjudication and coding rules and requirements.

Locate and download all coding sources for system updating.

Must have excellent verbal and written communication skills.

Performs other duties as assigned / necessary.

MINIMUM REQUIREMENTS

Minimum of five years’ experience in healthcare claims processing, or an equivalent combination of education, training, and experience

Medi-Cal and Medicare claim processing experience preferred

Strong understanding of claims processing workflow and payment rules

Detailed knowledge of electronic billing processes and universal billing forms

Knowledge of CMS pricers and vendor pricing software

Strong written skills to accurately complete required documentation within the time frames specified

EDUCATION & EXPERIENCE REQUIREMENTS

3+ years of experience within an MSO, IPA or Health Plan environment

Must be highly organized and able to perform multiple tasks efficiently, be computer literate and must be very knowledgeable of all claims processing rules and guidelines

Must have knowledge of CPT Codes and ICD9 Codes

Must have experience in processing all lines of business Medicare, Medi-Cal, and Commercial claims

Proficient in RBRVS, HCPCS, and CPT coding practices

Familiar with regulatory agencies such as CMS, DMHC, DHCS (State of Cal)

Familiar with required laws pertaining to HIPPA Security & Privacy, Fraud Waste and Abuse

Knowledge of health plans, medical groups, and managed care operations and related functions and regulations.

Relevant Bachelor’s degree; or equivalent work experience required.

Ability to work in a fast-paced environment.

Knowledge of software applications such as EZCAP.