Centers Plan for Healthy Living

  • Claims Audit Supervisor

    Job Locations US-NY-Staten Island
    Posted Date 5 months ago(7/2/2018 3:05 PM)
    # of Openings
  • Overview

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    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.





    • Lead team of auditors in conducting audits of CPHL claims processed internally or by Delegated Vendors utilizing CPHL guidelines, policies and procedures or any other regulatory requirements.
    • Distributes daily audit assignments and review audit results for accuracy and completeness.
    • Develops and maintains frequent audit reports and tracking sheets based on identified issues and recommendations of management.
    • Identifies defects and improves accurate provider payments by performing root cause analysis on specific examples through each step of the Claims Process.
    • Analyzes system and provider/member issues to determine trends and recommended changes in methods, procedures, policies, and systems to improve overall processing.
    • Identifies and follows up on critical root cause errors by quantity, financial impact, and complexity of issue.
    • Identifies, documents, tracks and reports to senior management on claim issues and trending results resulting from audits or other internal resources.
    • Reviews internal and Delegated Vendor production reports to ensure compliance with all regulatory requirements and CPHL policies.
    • Analyzes audit results to recommend system or procedural changes to increase claim accuracy and/or identify opportunities for workflow enhancements.
    • Maintains documentation of changes to claim processing guidelines and where appropriate, ensures policies and procedures are created or updated.
    • Communicates and follows up either orally or in writing with a variety of internal and external sources.
    • Evaluates Prospective Payment System (PPS) (e.g. APC, DRG, etc.) grouping and pricing information.
    • Meets individual and departmental standards with regards to quality and productivity.
    • Participates in audits of the Delegated Vendors and Compliance as required.
    • Provides expertise and assistance relative to provider billing and payment guidelines consistent with CPHL policies and procedures and State or CMS guidelines.
    • Performs other duties and special projects as assigned and directed.



    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:

    • Excellent analytical and problem solving skill.
    • Effective presentation skills
    • Excellent verbal and written communication skills
    • Ability to exercise good judgement in complex or difficult claim situations
    • Must be able to participate in meetings with all levels of management within the organization
    • Detail oriented and excellent follow up skills
    • Ability to multi-task in a fast paced environment and meet targeted audit goals
    • Must be service oriented, quick learner, and team player
    • Appreciation of cultural diversity and sensitivity toward target population



    Physical Requirements:

    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.




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