Sr. Claims Audit Manager - Community Health Choice
Harris Health System
Location: Houston, Texas
Type: Full Time
Internal Number: 160728
Accountable for oversight of Claims Department Training and Auditing Programs. Additionally, this position is responsible for pre-litigation and claim appeal file analysis. This position is responsible for monitoring and identifying inappropriate provider billing patterns. his position will be constantly auditing various provider claims to detect opportunities for improvement in claim payment, contracting and utilization management. Identify risks related to claims processing and work with Claims Operations to develop processing and payment workflows specific to Medicare/Medicare Advantage, Marketplace and Medicaid.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Essential Functions 15 % Apply policy interpretation related to appropriateness and accuracy of payment practices for Medicare Advantage, Medicaid and Marketplace 15 % Multi-tasker with extensive experience and judgment necessary to achieve key departmental audit initiatives 20 % Utilize experience with various payment methodologies and contract language to assess provider billing appropriateness and claim billing practices looking for potential fraud, waste, and abuse to complete audit requirements. 10 % Escalate quality issues to appropriate and submit timely notifications to Compliance Officers when necessary. 20 % Identify quality risks through auditing program and work with Operational leaders to implement appropriate strategies to mitigate risks identified. 10 % Compile weekly, Monthly, Quarterly, and Year to Date statistics related to Claims Audit
Marginal Functions 5 % Perform routine and ad-hoc analysis of processes related to deficiencies identified via auditing processes. 5 % Perform external delegation audit function (vision & dental providers) of audit program relative to claims payment
Reports to Position Title: Director Claims Employees Supervised Titles: Claims Supervisor
HS or equivalent
Work Experience (Years and Area):
Bachelors and 7 years claims managerial experience;
or 11 years of health plan leadership experience with a health plan or Third-Party Administrator in lieu of degree.
Preferred: Extensive knowledge of Medicare/Medicare Advantage processes and regulatory requirements and / or Knowledge of Medicaid and Marketplace claims processing requirements.
Management Experience (Years and Area):
5 years Management experience with health plan and/or Third-Party Administrator (TPA)
Preferred: 5 years leadership experience in auditing or claim appeals, preferably with Medicare /Medicare Advantage
Microsoft Office (Word, Excel, Outlook)
Claims Applications: QNXT or EPIC Systems a plus
Strong critical thinking and analytical skills required.
Excellent interpersonal, written and verbal communication skills required. Ability to maintain strict confidentiality.
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.