The Sr. Compliance Auditor, Claims is responsible for leading audits of external vendors and internal departments to ensure regulatory and contractual compliance requirements. The auditor also participates in the planning and development of tools, strategies, and educational resources that promote best practices in compliance.
Essential Job Functions:
- Lead compliance audits on Claims to review medical record documentation and coding/billing practices, assessing the accuracy of ICD-10-CM/PCS, CPT, HCPCS codes, modifier assignments, etc.; determining compliance with appropriate policies, procedures, and Federal and state regulations.
- Identify and provide guidance on remediation activities, train staff on compliance requirements and controls, if needed.
- Develops & implements unit workflows, audit tools, policies & procedures related to auditing and chart reviews.
- Assists in reviewing material for submission to audits (external, mock, or regulatory), and due diligence activities.
- Requires accurate tracking and recordkeeping; coordinating audits or interviews; and creating/delivering presentations.
- Facilitates the review and oversight process, including the corrective action updates.
- Interacts closely with other compliance department personnel on all compliance related activities.
- Conducts oversight audits of health plan procedures and processes to verify compliance with contractual and regulatory requirements and to identify fraud.
- Review and evaluate standards and processes that focus on accuracy, completeness, and timeliness.
Other Job Functions:
- Understand, adhere to, and implement the Company’s policies and procedures.
- Provide excellent customer services skills, including consistently displaying awareness and sensitivity to the needs of internal and/or external clients. Proactively ensuring that these needs are met or exceeded.
- Take personal responsibility for personal growth including acquiring new skills, knowledge, and information.
- Engage in excellent communication which includes listening attentively and speaking professionally.
- Set and complete challenging goals.
- Demonstrate attention to detail and accuracy in work product.
- Three years’ experience as a Claims Examiner or equivalent position (i.e. Appeals Analyst, Claims Adjuster, etc.)
- Requires specialized knowledge in the areas of contracts, Medicare Advantage, Medi-Cal HMO and commercial regulations and reimbursement rules and coordination of benefits
- Bachelor’s degree in Business, Health Care Administration or related field or equivalent education and experience
- Certified coder preferred