PL
Quality Auditor responsible for inspecting pallets and maintaining quality standards at PLA Supply Chain Services. Ensure safety rules and orderliness in the work area.
About the role
- Audit medical claims received from providers for adjudication accuracy. This includes both professional and institutional claims of all types
- 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 5 years of experience auditing medical claims
- Coding credential is required
- Preferred AHIMA CCS
- Required either CPC, CPC-A, RHIT, or CCS
- 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
- Knowledge of the 5010 data standards, along with practical understanding of EDI transmission files (835/837, 270/271, etc)
- 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, such as the No Surprises Act, ACA Preventive Health Provisions, parity laws
- 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 to drive compliance-friendly and business-friendly outcomes
- Strong organizational and project management skills with demonstrated attention to detail
- Proficiency with technology tools, including Google Drive, Sheets, Docs, Box, Smartsheet, Looker, and Slack
- 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
- Health insurance
- Stock options
- 401k
- Paid time off
- Flexible work arrangements
- Professional development opportunities
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