Healthcare Operations Specialist
6 days ago
Job Summary:
We are seeking a highly skilled and experienced professional to join our team as a Health Plan Operations Audit Expert with a specialization in Call Center and Claims Integrity Auditing for Medicare/Medicaid SNP (Special Needs Plan) claims.
This role is critical in ensuring compliance with regulatory requirements, maintaining claims accuracy, and optimizing operational efficiency within our organization's health plan offerings.
Key Responsibilities:
- Lead and oversee all aspects of claims integrity auditing processes for Medicare and Medicaid SNP claims.
- Develop and implement audit protocols, methodologies, and procedures to ensure comprehensive coverage and accuracy assessment.
- Conduct regular audits of claims data, documentation, and processes to identify discrepancies, errors, and areas for improvement.
- Collaborate with internal stakeholders, including claims processing teams, compliance officers, and data analysts, to address audit findings and implement corrective actions.
Requirements:
- Bachelor's degree in Healthcare Administration, Business Management, Finance, or related field; Master's degree preferred.
- Extensive experience (5+ years) in health plan operations, claims management, or auditing, with a focus on Medicare and Medicaid SNP claims.
- In-depth knowledge of Medicare and Medicaid regulations, policies, and procedures governing claims processing and billing.
- Proven track record of developing and implementing audit protocols, methodologies, and quality improvement initiatives.
- Relevant certifications (e.g., Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), Certified Internal Auditor (CIA)) preferred.
What We Offer:
At Raag Solutions, we offer a dynamic and challenging work environment that fosters growth and development. We are committed to delivering high-quality services to our clients and are seeking a talented individual to join our team.
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