Claims Audit Analyst - Denver Health Medical Plan (Must Live in Colorado. Weekly On-Site Requirement)

Denver Health•Denver, CO

7d•$60,500 - $87,700•Hybrid

About The Position

Under general supervision, the Claims Audit Analyst is responsible for benefit administration and assisting with the daily management of claims inventory. This role involves daily data analysis and research of claims processing to ensure benefit structures and operational processes adhere to the rules, regulations, and contractual requirements set by CMS, DOI, and contracted/non-contracted providers. The analyst will oversee the daily management of claims inventory through Business Management Services (BMS) for issue escalations or resolutions, acting as a liaison between software users and technical staff (BMS and IS). Additionally, this position will collaborate with the Compliance program to monitor and detect potential claims for fraud and abuse, interacting with all levels of management and employees.

Requirements

Bachelor's Degree required OR High school diploma or GED required AND an additional 4-6 years of claims experience in lieu of degree required
1-3 years claims experience required OR 7-9 years claims experience without Bachelor's degree required
Thorough knowledge of QNXT and benefit structure to ensure claims accuracy.
Ability to define problems, collect data, establish facts and draw valid conclusions.
Knowledge of all claim forms and coding types, including UB-04, CMS1500, ICD-9-CM, CPT-4, ICD-10-CM, HCPC, Revenue and NOC coding.
HIPPA, HEDIS.
Extensive knowledge of claims administration in a healthcare field.
Ability to lead/manage projects and interact with staff on all levels.
Able to implement testing material for changes with benefit structures for all lines of business.
Interact and collaborate with other corporate groups such as Provider Relations, Member Services, Information Systems, Compliance, Third Party Recovery, Finance, Patient Accounts, Enrollment, Utilization Management and Product Line Managers.
Key candidate will be adaptable; detailed oriented and have strong analytical skills.
Excellent verbal and written communication skills.
Access database, Reports, Queue's and other tools as needed.
Proficiency in Word, Excel, Webstrat, PowerPoint, Business Intelligence Portals and Audit Tool.

Nice To Haves

Experience with Medicare, Medicaid and Commercial programs preferred.
Total Claims Capture and Control (TC3) experience preferred.
Working knowledge of CMS/Medicare payment platforms a plus including the Resource Based Relative Value System (RBRVS) and Diagnostic Related Groups (DRG).

Responsibilities

Accurately perform audits on claims processed by the vendor. Perform special claims audits as assigned. Perform calibration “audit the auditor” assessments and share findings. (30%)
Review provider escalations and ad-hoc member/provider grievance and appeal reviews to address possible payment errors. Escalate any needed configuration changes. (20%)
Monitor member accumulators and log on Smartsheet any overage to Member Maximum Out of Pocket limits. Work with vendor to root cause & resolution (10%)
Address specific pricing needs including but not limited to: transplant pricing, DRG downcoding, NSA claims. (10%)
Review IDR NSA disputes, conduct greater of QPA reviews, log cases to Smartsheet, offer in compromise, route any arbitration cases for further assessment/completion. (10%)
Conduct weekly check run reviews for abnormalities for all plans based on summary reports to ensure that claim payments are adhering to the rules, regulations and contractual requirements. (10%)
Ad hoc work as required, including supporting the Claims Manager with data and analysis. (10%)

Benefits

Generous paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays
100% paid parental leave up to 6 weeks
Immediate eligibility for retirement plans with employer contribution up to 9.5%
Generous medical, dental, vision plans in addition to employer paid disability and life insurance.
Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center
Free RTD EcoPass (public transportation)
Childcare discount programs & exclusive perks on large brands, travel, and more
Tuition reimbursement & assistance
Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways
Professional clinical advancement program & shared governance
Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program
National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer