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Claims Audit Manager
1 month ago
Advanced Medical Manage (AMM) is seeking a highly skilled Claims Audit Manager to join our team. As a Claims Audit Manager, you will play a critical role in ensuring the accuracy and compliance of claims processing within our organization.
Key Responsibilities:- 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.
- Queries, analyzes, and interprets data for ad hoc analyses.
- Applies 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.
- Gathers information needed for compliance-related activities.
- Participates in quality assurance processes for all new department-related system/application/process changes.
- Performs 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.
- Demonstrates attention to detail and accuracy in work product. Supports all levels of claims staff regarding Medicare Commercial, and Medi-Cal, adjudication and coding rules and requirements.
- Locates and downloads all coding sources for system updating.
- Must have excellent verbal and written communication skills.
- 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.
- 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.
