Responsible for conducting or assisting in the documentation of audit projects. May conduct internal, ride along, and/or on-site audits. Assists in the development of monitoring standards. Responsible for verbal and written communications, internally and/or externally, accuracy of files, and system timeliness for process inquiries to meet regulatory standards. Includes Claims, Customer Service, Network Operations, Regulatory Management, Health Services, Pharmacy, Sales, Enrollment, Compliance, Coding, Credentialing, and other departments.
Responsible for ensuring compliance with governmental (CMS, SOX, etc), departmental, and company guidelines. May audit claims for coding accuracy, benefit payment, contract interpretation. May identify billing abnormalities, questionable billing practices, and/or irregularities. May monitor and evaluate the quality of inbound and/or outbound customer service calls. May audit application and member demographic entries to ensure accuracy. May audit third party vendors. May track complaint trends and progress towards resolution. May report deficiencies according to specific plan procedures. May analyze data to identify significant trends and opportunities for improvement. May assist in the development of department goals and objectives. May audit prior authorization requests for appropriate determination and data entry accuracy. May audit accuracy and timeliness of credentialing verification process and files; design and execute reports related to compliance with regulatory and health plan standards. May be responsible for quality review of health management reports. May attend evening meetings / events. May oversee secret shopping program to assess sales agent performance against CMS requirements for a compliant sales presentation. May identify opportunities and provide training and education to employees, providers, staff, or others.
High school education or equivalent is required (Bachelor’s degree or Licensure in a health-related field preferred).
Working knowledge of governmental guidelines, managed care, and Medicare.
At least three or more years of related experience.
Bilingual skills preferred.
Effective communication skills.
Sales or Medicare Customer Service experience preferred.
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