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Claims Audit Manager
1 month ago
Job Summary:
We are seeking a highly skilled Claims Audit Manager to join our team at Advanced Medical Manage. The successful candidate will be responsible for ensuring the accuracy and compliance of claims processing, as well as providing expert guidance on Medicare and Medi-Cal claim payment rules and requirements.
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.
- Performs other duties as assigned/necessary.
Requirements:
- 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.
Education & Experience Requirements:
- 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.
