Senior Lead Auditor responsible for conducting audits against relevant standards at Bureau Veritas. Coordinating audit processes and ensuring compliance with regulatory requirements.
About the role
- Auditor ensuring compliance in claims processing at Collective Health, a healthcare technology company. Responsible for developing compliance programs and collaborating across teams.
Responsibilities
- Create electronic claims accuracy monitoring mechanisms utilizing claims data models to identify potentially non-compliant claim adjudications.
- Develop and implement automated claims audits utilizing purposeful review of claims patterns and data analytics to proactively identify adjudication inaccuracies.
- Work cross-functionally with data analytics, data engineering, and other operational teams to identify and remediate claims errors based on data patterns.
- Audit medical claims received from providers for adjudication accuracy, including professional and institutional claims.
- Manage internal and external audits.
- Provide timely input on compliance-related issues and guidance requests.
- Assist with compliance risk assessments and audit readiness.
- Assist with new compliance regulation implementation related to claims accuracy.
- Collaborate with team members to identify and mitigate compliance risk for claims.
- Work closely with Collective Health attorneys to receive and coordinate legal guidance needed to operationalize important initiatives and requirements.
Requirements
- Bachelor's degree or equivalency required, preferably in a business, technology, or healthcare field.
- At least 8 years of experience performing data analyses on complex medical claims data sets.
- A coding credential is required, preferably AHIMA CCS, or CPC, CPC-A, RHIT.
- Broad experience and knowledge of coding and reimbursement systems (MS-DRGs, PPS Systems, bundled payments, OPPS, value-based care, FFS).
- Broad experience and knowledge of healthcare and healthcare business practices and principles.
- Broad experience and knowledge of third-party payer practices, including precertification, timely filing, claims processing, coverage, and payer rules.
- Broad experience and knowledge of healthcare claims data and analytics.
- Knowledge and applicable understanding of federal laws related to ERISA group health plans and state department of insurance laws.
- Knowledge of the 5010 data standards, along with practical understanding of EDI transmission files (835/837, 270/271, etc.) and all X12 data specifications.
- Knowledge and applicable understanding of subrogation, coordination of benefits, and claims hierarchy standards.
- Knowledge and applicable understanding of state and federal laws which apply to claims processing for group health plans.
- Experience developing or enhancing a compliance program is desired.
- A CHC certification is preferable.
- Proven ability to build relationships and to collaborate effectively with a broad range of stakeholders and departments.
- Strong organizational and project management skills with demonstrated attention to detail.
- Proficiency with technology tools, including Google Drive, Sheets, Docs, Box, Smartsheet, Looker, Slack, and Databricks.
- Critical thinking and decision-making skills, with the ability to quickly determine issues that need escalation.
- Excellent written and verbal communication skills (including presentations) and the ability to drive execution in a team environment.
Benefits
- Stock options
- Health insurance
- 401k
- Paid time off
- Flexible work arrangements
- Professional development opportunities
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