Director of Claims Audits

About Us

All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients.  ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees.  We also offer paid holiday, sick time, and vacation time as well as a 401k plan.  Additional employee paid coverage options available.

Job purpose

The Director of Claims Audits is responsible for post and pre auditing institutional and professional claims according to established line of business guidelines, policies and procedures.  This job includes achieving 95% or higher claims compliance. Process improvement of the claims process to achieve quality claims adjudication within CMS, DHCS and DMHC timeliness guidelines.

Duties and responsibilities

Institutional Claims Review for accuracy and timeliness using HP audit tools to capture Root Cause, Remediation and QA monitoring.

Professional Claims Review for accuracy and timeliness using HP audit tools to capture Root Cause, Remediation and QA monitoring.

Claims system quality improvement collaboration (all departments that touch a claim)

Collaborative Claims team training on items found during audits for process improvement

Claims workflow monitoring (all departments that touch a claim)

Other requests as needed

Qualifications

10+ years or more experience in processing HMO claims in a managed care environment.

Proficient in rate application for all payments methods by lines of business. (Medicare, Commercial, Medi-Cal). Including but not limited to, NCCI/CCI edits, CMS Medicare, Medi-Cal, RNC, outpatient PPS & Inpatient DRG facility, ASC, APC, Interim Rate Payment

Expert with all regulatory requirements including CMS, DMHC and DHS.

Proficient with all Federal and state requirements in claim processing.

Knowledge of medical terminology and coding.

Recognize the difference between Shared Risk and Full Risk claims.

Proficient in applying Division of Financial Responsibility.

Knowledgeable in applying Health Plan Benefit Matrices.

Proficient understanding of AB1324.

Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations.

Medical Record Coding Review as it pertains to administrative billing and coding.

Excellent communication skills including reports, correspondence, and verbal communications.

Demonstrated proficiency with Microsoft Word and Excel.