Auditor, Compliance

Regal Medical Group•Los Angeles, CA

3d•$30 - $32

About The Position

The Claims Compliance Auditor is responsible for performing activities related to benefit analysis and system design, manage special projects, claim denials and auto-adjudication applications as it applies to auditing and claims compliance. This includes oversight of all workflow, research and documentation under limited supervision by the Claims management. Identifies potential company risks and implements appropriate courses of action and develop strategies to reduce adjudication errors. Analyzes all relevant information to track and trend the special projects outcomes to provide findings to appropriate management.

Requirements

5 years working knowledge of claims processing and system configuration, preferably EZCap or like systems in the healthcare system,
Strong ability to collaborate with management and other project managers to define business process issues, analyze operational efficiencies, implement creative solutions, and measure delivery results.
Should exhibit a disciplined, process and data-driven approach and
Knowledge of claims processing and regulatory agencies requirements
Requires strong organizational, communication and written
Must be able to function with minimal supervision and be able to prioritize all work
Demonstrated ability to conduct and interpret qualitative and quantitative analysis and problem-solving skills.
Ability to work well with individuals in all levels of the organization; must be an effective team player
Demonstrated ability to exercise initiative, independent judgment and be a self-
Strong PC-based business software skills including MS Office suite (Access, Excel, PowerPoint, Word).

Responsibilities

Utilizes standardized processes, tools, methodologies and presentation templates, progress/milestone reports, track audit issues.
Communicates effectively with all appropriate internal and external individuals, as well as maintain regular contact with the Claims and Finance management and other project sponsors to coordinate project activities as appropriate.
Prepares and presents regular project progress reports for Claims management and other project sponsors such as Finance management as it relates to claims compliance.
Also works closely with other members of Finance and Claims management to plan project activities such as, but not limited to, Auto-adjudication, system pricing, training development based upon claims compliance.
Responsible for auditing denied
Responsible for assisting with health plan and regulatory audit preparations; such as scheduling, compile/vet audit universe reports, any additional documents required and results.
Responsible for assisting in development and testing of auto-adjudication
Ability to translate health benefit plan design, claims, health related insurance products into systems configuration.
Provides technical support, training assistance, and expertise to Claims staff or other department as determined through all phases of the project (e.g., Research, Outcomes, Provider notification of findings).
All other duties as directed by management
Proactively support and practice company mission, vision and values.
Follow Employee Handbook guidelines and company policies and procedures.
Follow established departmental dress code.
Appropriately and accurately maintain time keeping records.
Adhere to attendance policy and time off requests.
Follow safety policies and procedures.
Be flexible and adaptable and courteous and promote professionalism.
Communicate verbally and in writing through appropriate channels.
Maintain confidentiality at all times in compliance with company policy and HIPAA requirements.
Employee has completed all required annual Compliance training and signed attestation form is attached for each module.