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Sr Compliance Auditor, Claims

agilon health Corona, CA
  • Expired: 4 days ago. Applications are no longer accepted.

Position Summary:

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.

Required Qualifications:

Minimum Experience

  • 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

Education/Licensure:

  • Bachelor’s degree in Business, Health Care Administration or related field or equivalent education and experience
  • Certified coder preferred

agilon health

Why Work Here?

Awesome leadership, great benefits, opportunity for growth and putting your stamp on things!

The passion to change the way healthcare is delivered permeates everyone and everything at agilon health. Working together we can use our expertise to make a difference in the lives of patients and physicians alike. We can bring the joy back to practicing medicine for physicians and improve the care experience for patients across the country. We believe that every member of our team plays a critical role in transforming care for our patients. Our customer service teams are the front line for physicians and patients navigating the system and, without our claims processing departments, our health plan partners and provider networks couldn’t do their jobs. No matter what your role is at agilon health, you can and will make a difference in the lives of the seniors and Medicaid populations we serve. Our culture and passion has already been embraced by nearly 500 employees in three states. And we are excited to welcome new members to the team as more physicians and patients experience the difference agilon health can make.

Address

Corona, CA
USA

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