Claims Compliance Auditor/Trainer
Curative Health Holdings, Inc is searching for a Compliance Analyst/ Auditor/ Trainer to audit claims for completeness and that they are processed per plan guidelines, audit all lines of business and complete regulatory audit requests. Performs all duties while maintaining compliance and confidentiality and promoting the mission of the organization.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Reviews claims, appeals and reconsiderations for compliance with plan guidelines and approves or denies payment using established guidelines, policy and procedures and plan directives.
- Documents clearly and concisely all claims adjudication decisions in Claim Notes.
- Consults appropriate reference materials to verify proper coding.
- This role will be the lead team trainer responsible for learning new systems, processes and functions and train and monitor the team to successfully complete those duties, processes
- Identifies potential problems and claims training issues discovered during review of claims referrals and appeals; refers for resolution to manager; tracks and trends claim processing errors.
- Coordinates adjudication of claims against the eligibility of individual enrollees as well as authorizations and benefit verification.
- Proactively identify processes and system problems than could be improved, to reduce rework and provide accurate payment upon original processing.
- Completes all required audits and reviews for TDI audits and any other state audit requests.
- Maintains timely responses to appeals and reconsideration requests
- Develops policies and performs departmental training, functions, and meetings.
- Ability to meet/maintain the required accuracy and production standards after release from training.
- Handles “special projects” as dictated by the client’s request. Reviews for claim payment accuracy, member out of pocket calculation accuracy (if applicable), etc.
- Adheres to rules and regulations of Curative as described in the employee handbook and in the unit/department/clinic procedures
- Creates databases, spreadsheets, or tables as required to facilitate the compilation of data for special project and/or ad hoc reporting assignments.
- Provides review and mentoring for other SAU Analysts and Claims department.
- Performs other duties, functions, and projects, as assigned, by team management.
- Travel Requirements: None
- At least 3 years of experience in claims benefit review/ adjudication, including PPO and/or Medicaid. Experience with various claim payment systems in processing hospital, mental health, dental and routine medical claims within given deadlines.
- Experience working on/ with the VBA claims system would be extremely beneficial in this role
- At least 2 years medical claim Auditing experience Knowledge of facility and professional claims including MSDRG and APC
- Interpret and apply plan guidelines while processing to ensure correct plan setup.
- Knowledge of medical terminology, ICD-10, CPT, and HCPCS coding
- Knowledge of TDI and CMS regulations and multi- states regulation/audit experience would be beneficial
- Experience with multiple states prompt pay guidelines (FL and TX) preferred
- Excellent Working Knowledge of MS Access, Google Sheets, SQL, and Excel required
- Excellent computer and keyboarding skills, including familiarity with Windows
- Excellent interpersonal & problem-solving skills.
- Excellent verbal and written communication skills to communicate clearly and effectively to all levels of staff, members, and providers.
- Ability to be detail oriented, focused, and sit for extended periods of time at a computer workstation.
- Ability to work in a team environment and manage competing priorities
- Ability to calculate allowable amounts such as discounts, interest, and percentages
REQUIRED EDUCATION, LICENSES and/or CERTIFICATIONS
- High school diploma or equivalent.
- CPMA -Preferred not required.