Claims Audit Manager

Job Description

Job Description

POSITION SUMMARY

Strong background on Medi-Cal, Commercial, and Medicare benefits, including coordination of benefits. Works closely with all departments necessary to ensure that processes, programs and services are accomplished in a timely and efficient manner in accordance with AMM policies and procedures and in compliance with applicable state and federal regulations including CMS, MediCal, and DMHC. Claims audit manager ensures incoming claims are processed in accordance with policies, procedures and guidelines , as outlined by AMM and contractual agreements; within mandated timeframes; and according to rate as reflected in respective provider contracts. Manager will be responsible for prepayment, post payment validations and the management of operational reporting, testing and data submissions.

RESPONSIBILITIES-DUTIES

• Prepares and coordinates the completion of complex regulatory and compliance reports for submission.
• Assists in audit preparations, analyzes information, identifies deficiencies, and tracks corrective action for completion. Processes additional data into the system, ensures that data was processed and researches any interruptions to the process.
• Query, analyze, and interpret data for ad hoc analyses.
• Apply Medicare Claim Payment rules and requirements, including the application of National Coverage Decisions, Local Coverage Decisions, and National Correct Coding requirements to claims received for payment.
• Gather information needed for compliance related activities.
• Participates in quality assurance process for all new department related system / application / process changes.
• Perform pre-payment audits and post payment audits to validate claims for appropriate coding and documentation and validate accurate claim adjudication rules and fee schedules were applied
• Ability to understand, work with and organize data from various systems and databases : facts, figures, narratives, and data analysis.
• Demonstrate attention to detail and accuracy in work product. Support all levels of claims staff regarding Medicare Commercial, and Medi-Cal, adjudication and coding rules and requirements.
• Locate and download all coding sources for system updating.
• Must have excellent verbal and written communication skills.
• Performs other duties as assigned / necessary.

MINIMUM REQUIREMENTS

EDUCATION & EXPERIENCE REQUIREMENTS