Claims Audit
1 month ago
About us:
Solis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected, and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert individuals that take pride in delivering quality service. We believe in a culture that collaborates and supports one another, and where success is interlinked, and each employee is valued. Please check out our company website at www.solishealthplans.com to learn more about us
Position is fully onsite Monday-Friday.
Location: 9250 NW 36th St, Miami, FL 33178.
***Bilingual in English & Spanish is required***
Full benefits package offered on the first of the month following date of hire including: Medical, Dental, Vision 401k plan with a 100% company match
Our company has doubled in size and we have experienced exponential growth in membership from 2,000 members to almost 7,000 members in the last year
Join our winning Solis Team
Position Summary:
The primary responsibilities for this position are to analyze and identify claim overpayments, effective communication (both written and verbal) to validate and recover overpayments, maintaining files with current up to date information and documentation. Types of overpayment reviews will include, but are not limited to: Duplicate Payment, Contract Compliance, Authorizations, Eligibility, Coordination of Benefits, Medical Review, DRG Review, Medicare, and Medicaid reimbursement policies.
Duties and Responsibilities:
- Make sure to review daily claims Inquiry.
- Analyze claims payment history and provider contracts to identify and determine where overpayment recoveries exist.
- Conduct root cause analysis on systemic issues; formulate action plan to avoid incorrect payment through review of contracts, Medicare claims payment rules, internal system, and beneficiary impact.
- Documentation of all related recovery efforts in different claims and database systems to document recovery efforts as required by each specific client.
- Perform documentation and coding audits, reviewing medical claims, records, and charges to ensure compliance with CPT coding and ICD10 coding standards.
- Maintain KPI’s daily counts.
- Analyze monthly CMS reports.
- Analyze current payment policies and make recommendations to improve program integrity and organizational processes.
- Oversee all inquiries that come in from either member services or providers with questions, claims statuses, EOP’s.
- Reviewing of itemized bills and reviewing cases with UM team.
- Generate letters to advise if claims on file along with spreadsheet of payments made.
- Review correspondence received from Insurance Companies or Attorney Offices.
- Draft written reports that detail audit findings and recommendations to senior leadership, Department management/personnel, and/or other related business partners.
- Ensure timely and accurate completion of recovery projects and related reporting.
- Establish communication and rapport with clients, members, and providers.
- Research, resolve, and respond to correspondence (both written and verbal) from members, providers, and clients.
- Follow all applicable State and Federal laws related to recovery efforts.
- Timely follow up on all files.
- Performed additional duties as assigned.
Qualifications and Education:
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.
Skills and Ability:
- Knowledge of automated claims processing systems and other complex claim processing rules and regulations.
- Proficient in processing / auditing claims for Medicare plans.
- Follow all appropriate Federal and State regulatory requirements and guidelines applicable to Health Plan operations.
- Excellent communication, organizational, and interpersonal skills (both written and verbal).
- Ability to work independently while maintaining a relationship and working with other team members.
- Ability to learn and adapt to various claim system platforms and analyze claim payments for validation of potential other payor liability.
- Strong computer skills with experience in Microsoft Word and Excel a plus.
- Thorough knowledge and understanding of medical claims terminology.
- Ability to handle multiple tasks in a fast-paced environment and meet deadlines.
- Proven ability to work under high production and quality standards.
- Proven analytical, collections, and problem-solving skills.
- Position may require flexible hours, and unscheduled overtime.
Education and Experience:
- Bachelor’s degree preferred.
- 2-3 years’ experience in medical claims processing and 1- 2 years’ experience in claims auditing.
- 2 years’ experience in a managed healthcare environment related to claims processing/auditing, including Medicare plans.
- 2 years’ experience with CMS requirements, and other complex claim processing rules and regulations.
- years’ experience using Healthcare Common Procedure Coding Systems (HCPCS), CPT, ICD, Medicare codes. Collections/recovery and/or accounts receivable experience preferred.
- Familiarity with health benefits and provider contract provisions is preferred.
- Self-motivated, goal-oriented individual with the ability to work in a fast-paced and demanding work environment.
Mathematical Skills:
- Ability to compute and validate claim payments to calculate recovery amounts.
- Ability to use formulas, and charting features within spreadsheets.
What Set Us Apart:
Join Solis Health Plans as Claims Audit & Recovery Manager become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference
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