Appeals / Audit / Compliance Coordinator
Job Title Appeals / Audit / Compliance Coordinator Requisition Number 7683
Reg/Temp Regular Employment Type Full-Time
Shift .. Work Schedule ..
Location Name Business Services Building City SALT LAKE CITY
State UT Department UIP CST 01H HEALTH PLANS ADMIN
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The University of Utah Health Care is an Affirmative Action/Equal Opportunity employer. Upon request, reasonable accommodations in the application process will be provided to individuals with disabilities. The University of Utah Health Care is committed to diversity in its workforce. Women and minorities are encouraged to apply.
More information about this job:Overview:
As a patient-focused organization, the University of Utah Health Care exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health Care seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, diversity, integrity, quality and trust that are integral to our mission.
This position supports the University of Utah Health Plans by participating in the auditing, improvement, maintenance, and evaluation of its programs and activities.
1. Manage all aspects of the Medicare, Medicaid and Commercial Appeals and Grievance program.
1. Coordinates and maintains a system for receiving, processing, and resolving provider and member appeals and grievances in accordance with all applicable contract provisions, plan policies, procedures, rules and regulations.
2. Develops and manages the policy and procedures according to Federal and State regulations by insurance plan.
3. Designs and reports outcomes to key contract stakeholders.
4. Analysis of trends for internal monitoring purposes and external reporting.
5. Manages the communication with the CMS third party appeals vendors; currently Maximus and C2C.
6. Manages the communication with the IRO’s for the commercial insurance plan
7. Designs the communications (written and verbal) according to the appropriate grade level and other regulations. Manages the multiple letters.
8. Manages the turn-around times / response times. Responsible for keeping the department within compliance.
1. Manage all aspects of compliance to the current Medicare, Medicaid and Commercial contracts:
1. Preparing for the annual Medicaid quality assessment and performance review.
2. Coordinating Medicare audits with the appropriate internal staff; claims, customer service, provider credentialing, etc.
3. Responsible for the contract deliverables and reports as outlined in the contracts.
4. Identifies compliance issues and implements corrective action plans
1. Program integrity in all areas and functions within the health plan (start to finish):
1. Audits operational functions and internal processes
2. Audits pertaining to fraud, waste, and abuse
3. Analysis of audits for quality improvement opportunities
Bachelor’s degree in a health related discipline or business and one year of related experience or equivalency required.
Excellent interpersonal, problem solving, and verbal and written communication skills as demonstrated by the ability to effectively convey information and collaborate with internal and external customers including staff, health plan management, and governmental agency personnel.
Experience and knowledge regarding insurance plans, medical coding, auditing, and contract compliance preferred. An intermediate level of proficiency with Word and Excel.
Demonstrated ability to perform the essential functions of the job as outlined in the job description.
University of Utah Health - 21 months ago