PIH Health Hospital
Overview
The Supervisor, Claims Audit is responsible for overseeing and managing claims auditors/trainers and ensuring that all policies and procedures are enforced as they relate to health plans and regulatory agencies requirements. This role understands claims payments/processes, compliance, audits, policies and procedures, state and federal regulations, health plan contracts, provider contracts, reimbursement, and audits. Will provide leadership in performance management of claims audits and training. Reports to the Director of Claims. Responsible for the day-to-day management of claims audits, and training of claims examiners. Will ensure that all claims examiners are fully trained and equipped to meet or exceed their productivity, process claims in accordance with contracted and non-contracted providers, and meet health plans’ and regulatory agencies’ requirements.
Responsibilities
Oversee and manage claims auditors/trainers to ensure enforcement of policies and procedures related to health plans and regulatory requirements.
Provide leadership in performance management of claims audits and training.
Manage day-to-day operations of claims audits and training of claims examiners.
Ensure claims examiners are fully trained and equipped to meet or exceed productivity targets and to process claims in accordance with contracted and non-contracted providers, while complying with health plan and regulatory requirements.
Qualifications
Experience in processing professional (CMS-1500) and institutional claims (UB04).
Expert in HCPCS/CPT codes, ICD-10s, RBRVS, etc.
Excellent oral and written communication skills.
Ability to train, coach, and mentor staff.
Knowledgeable in provider contracts and health plan agreements.
Experience paying, denying, and processing claims.
Knowledgeable in commercial, Medicare, and Medi-Cal reimbursement methodologies (e.g., fee schedules, OPPS, MS-DRG).
Knowledgeable in eligibility, benefits, evidence of coverage, EOB, and remittance advice.
Able to work well with all levels of management.
Excellent problem-solving, decision-making, and analytical skills with ability to work in a team environment.
Ability to identify problems, develop solutions, and take action to resolve them.
Fully developed skills in: claims production, claims audit, claims adjudication process, physician billing/coding, contracts analysis, customer/member service, PC skills, and effective communication and presentation skills.
Full knowledge of regulatory requirements from CMS, DMHC and DHS.
Thorough understanding of reimbursement methodologies as they relate to managed care contracting.
Minimum five years’ experience in managed care and supervising.
Bachelor's degree in Business Administration, Accounting, Finance or Healthcare Management (preferred).
Details Address:
6557 Greenleaf Ave.
Salary:
33.00-47.53
Shift:
Days
Zip Code:
90601
#J-18808-Ljbffr
Responsibilities
Oversee and manage claims auditors/trainers to ensure enforcement of policies and procedures related to health plans and regulatory requirements.
Provide leadership in performance management of claims audits and training.
Manage day-to-day operations of claims audits and training of claims examiners.
Ensure claims examiners are fully trained and equipped to meet or exceed productivity targets and to process claims in accordance with contracted and non-contracted providers, while complying with health plan and regulatory requirements.
Qualifications
Experience in processing professional (CMS-1500) and institutional claims (UB04).
Expert in HCPCS/CPT codes, ICD-10s, RBRVS, etc.
Excellent oral and written communication skills.
Ability to train, coach, and mentor staff.
Knowledgeable in provider contracts and health plan agreements.
Experience paying, denying, and processing claims.
Knowledgeable in commercial, Medicare, and Medi-Cal reimbursement methodologies (e.g., fee schedules, OPPS, MS-DRG).
Knowledgeable in eligibility, benefits, evidence of coverage, EOB, and remittance advice.
Able to work well with all levels of management.
Excellent problem-solving, decision-making, and analytical skills with ability to work in a team environment.
Ability to identify problems, develop solutions, and take action to resolve them.
Fully developed skills in: claims production, claims audit, claims adjudication process, physician billing/coding, contracts analysis, customer/member service, PC skills, and effective communication and presentation skills.
Full knowledge of regulatory requirements from CMS, DMHC and DHS.
Thorough understanding of reimbursement methodologies as they relate to managed care contracting.
Minimum five years’ experience in managed care and supervising.
Bachelor's degree in Business Administration, Accounting, Finance or Healthcare Management (preferred).
Details Address:
6557 Greenleaf Ave.
Salary:
33.00-47.53
Shift:
Days
Zip Code:
90601
#J-18808-Ljbffr