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Claims and Vendor Auditor
2 months ago
Who you are:
As the Vendor Auditor for Johns Hopkins Health Plans (“JHHP”), your in-depth knowledge of auditing, claims, and medical policy helps ensure that our vendors are performing to policy and regulations. Not only will you lead audits, you will also report out to the oversight committees and lead in audits performed by regulatory and accreditation agencies.
What you’ll do:
- Day-to-day management of auditing for JHHP’s highest risk vendor population
- Analyze data to assess the accuracy of claims payments
- Identify trends and anomalies within claims data and perform root cause analysis
- Review contracts, including SLA’s, to determine if vendor standards are met
- Communicate audit results in a formal report within required timelines
- Monitor state and federal rule changes for impact on claim payments and update audit criteria as necessary
- Assist with special projects
- Escalate concerns to departmental leadership and JHHP Chief Counsel
What you’ll bring:
- Experience in quality audits of claims, general relationship oversight auditing, and be able to apply skills to auditing existing vendor relationships
- 2+ years of pharmacy, medical or PBM claims processing or auditing experience
- 2+ years of experience working independently in auditing role
- Knowledge of claims system software
- Strong knowledge of Medicare and Medicaid reimbursement rules
- Knowledge of authorizations, appeals, and medical reimbursement policies
- High level of interpersonal skills and ability to analyze situations
- Advanced MS Office computer skills
- Excel (with pivot charts), Word, and Power Point
- College degree in Nursing, Accounting, Business, or Healthcare
- 3 years of advanced claims auditing experience will be considered in lieu of college degree
Who we are:
Johns Hopkins Health Plans (JHHP) is the managed care and health services business of Johns Hopkins Medicine, based out of Hanover, MD. JHHP is a $3B business serving nearly 500,000 active members with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHP is a leader in provider-sponsored health plans and is poised for future growth.
Many organizations talk about transforming the future of healthcare, at Johns Hopkins Health Plans, we are setting the pace for change within the healthcare industry. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for our members and the communities we serve. If you are interested in improving how healthcare is delivered, and have a passion to be at the forefront of change, JHHP is the place to call home.
Please note: US citizenship is required for this position as it falls under the terms of a government contract (to ensure compliance with DODPSP).
This position is eligible for remote work.
Johns Hopkins Health System and its affiliates are drug-free workplace employers.
