Responsible for leading team of auditors in claims auditing functions of Centers Plan for Healthy Living (CPHL) including analyzing payments, procedures, and guidelines of benefits. Collaborates with other Health Plan departments and Delegated Vendors to ensure claims are processed in accordance with Federal, State and CPHL established guidelines and/or policies and procedures. Assists in and/or participates in compliance reviews of Delegated Vendor’s claims processing policies and procedures. Provides feedback or suggestions to enhance current processes and/or systems.
Education and Experience:
Required: BA/BS degree in a financial field or equivalent healthcare experience
Type of Experience
Required: 4+ years of claim processing and auditing experience with a Medicaid/Medicare Health Plan.
Specific Technical Skills
Required: Use of Microsoft Access or similar query tool. Proficiency with MS applications, including but not limited to Word, Excel, Outlook, Power Point.
Knowledge and Skills:
The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification. They should not be construed as an exhaustive list of all responsibilities, duties and skills required.