Claims Audit Manager
2 months ago
Job Summary:
Advanced Medical Manage is seeking a highly skilled Claims Audit Manager to join our team. As a Claims Audit Manager, you will be responsible for ensuring that incoming claims are processed in accordance with policies, procedures, and guidelines, as outlined by Advanced Medical Manage and contractual agreements.
Key Responsibilities:
- Prepayment and Postpayment Audits: Conduct prepayment and postpayment audits to validate claims for appropriate coding and documentation and ensure accurate claim adjudication rules and fee schedules were applied.
- Claims Processing: Process incoming claims in accordance with policies, procedures, and guidelines, as outlined by Advanced Medical Manage and contractual agreements.
- Regulatory Compliance: Ensure compliance with applicable state and federal regulations, including CMS, Medi-Cal, and DMHC.
- Reporting and Data Analysis: Manage operational reporting, testing, and data submissions.
- Quality Assurance: Participate in quality assurance process for all new department-related system/application/process changes.
- Communication: Demonstrate excellent verbal and written communication skills to support all levels of claims staff regarding Medicare, Commercial, and Medi-Cal adjudication and coding rules and requirements.
Requirements:
- Experience: Minimum of five years' experience in healthcare claims processing, or an equivalent combination of education, training, and experience.
- Medi-Cal and Medicare Experience: Preferred experience in Medi-Cal and Medicare claim processing.
- Claims Processing Knowledge: Strong understanding of claims processing workflow and payment rules.
- Electronic Billing: Detailed knowledge of electronic billing processes and universal billing forms.
- CMS Pricers and Vendor Pricing Software: Knowledge of CMS pricers and vendor pricing software.
- Organizational Skills: Highly organized and able to perform multiple tasks efficiently.
- Computer Literacy: Computer literate and knowledgeable of all claims processing rules and guidelines.
- Coding Knowledge: Knowledge of CPT Codes and ICD9 Codes.
- Healthcare Industry Knowledge: Familiar with regulatory agencies such as CMS, DMHC, DHCS (State of Cal), and required laws pertaining to HIPPA Security & Privacy, Fraud Waste and Abuse.
- Education: Relevant Bachelor's degree; or equivalent work experience required.
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