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PIH Health · 2 hours ago

Claims Audit Supervisor, FT Days

Whittier, CA

Full-time

Onsite

Senior Level

$33/hr - $47.53/hr

5+ years exp

PIH Health is a nonprofit regional healthcare network serving approximately 3 million residents in the Los Angeles County area. The Claims Audit Supervisor is responsible for overseeing claims auditors and ensuring compliance with health plans and regulatory agencies, while also providing leadership in performance management and training of claims examiners.

Health Care

Responsibilities

Overseeing and managing claims auditors/trainers

Ensuring all policies and procedures are enforced as it relates to health plans and regulatory agencies requirements

Providing leadership in performance management of claims audits and training

Managing day-to-day claims audits

Training claims examiners to meet or exceed productivity and process claims in accordance with provider contracts

Meeting health plans’ and regulatory agencies’ requirements

Qualification

Claims processingHCPCS/CPT codesReimbursement methodologiesProvider contractsClaims auditCommunication skillsProblem-solving skillsTeamworkLeadership

Required

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 (i.e. fee schedules, OPPS, MS-DRG, etc.)

Knowledgeable in eligibility, benefits, evidence of coverage, EOB, and remittance advise

Able to work well with all levels of management

Excellent problem-solving skills, decision-making skills, and analytical skills coupled with the ability to work successfully in a team environment

Ability to take initiative in identifying problems, developing solutions, and taking the necessary action to resolve the problems

Fully developed skills in the following areas required: claims production, claims audit, claims adjudication process, physician billing/coding, contracts analysis, customer/member service, personal computer (spreadsheet, database, word processor), and effective communication and presentation skills

Has full knowledge of all regulatory requirements from CMS, DMHC and DHS

Thorough understanding of reimbursement methodologies as they relate to managed care contracting

Minimum five years' experience in managed care and supervising