PIH Health
Overview
Join to apply for the
Claims Audit Supervisor, FT Days
role at
PIH Health . Responsibilities
Oversee and manage claims auditors/trainers and enforce policies and procedures as they relate to health plans and regulatory agencies requirements. Understand claims payments/processes, compliance, audits, policies and procedures, state and federal regulations, health plan contracts, provider contracts, reimbursement, and audits. Provide leadership in performance management of claims audits and training. Report to the Director of Claims. Manage day-to-day claims audits and training of claims examiners; ensure examiners are fully trained to meet productivity goals and to process claims in accordance with contracted and non-contracted providers, while meeting health plans’ 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 (spreadsheet, database, word processor), and effective communication and presentation skills. Full knowledge of regulatory requirements from CMS, DMHC and DHS. Thorough understanding of reimbursement methodologies related to managed care contracting. Required Experience
Minimum five years’ experience in managed care and supervising. Preferred Education
Bachelor's degree in Business Administration, Accounting, Finance or Healthcare Management. Details
Location: 6557 Greenleaf Ave., Whittier, CA 90601 Salary: 33.00-47.53 Shift: Days
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Join to apply for the
Claims Audit Supervisor, FT Days
role at
PIH Health . Responsibilities
Oversee and manage claims auditors/trainers and enforce policies and procedures as they relate to health plans and regulatory agencies requirements. Understand claims payments/processes, compliance, audits, policies and procedures, state and federal regulations, health plan contracts, provider contracts, reimbursement, and audits. Provide leadership in performance management of claims audits and training. Report to the Director of Claims. Manage day-to-day claims audits and training of claims examiners; ensure examiners are fully trained to meet productivity goals and to process claims in accordance with contracted and non-contracted providers, while meeting health plans’ 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 (spreadsheet, database, word processor), and effective communication and presentation skills. Full knowledge of regulatory requirements from CMS, DMHC and DHS. Thorough understanding of reimbursement methodologies related to managed care contracting. Required Experience
Minimum five years’ experience in managed care and supervising. Preferred Education
Bachelor's degree in Business Administration, Accounting, Finance or Healthcare Management. Details
Location: 6557 Greenleaf Ave., Whittier, CA 90601 Salary: 33.00-47.53 Shift: Days
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