Bhs - Senior Claims Auditor And Compliance Specialist
Company Name:
ValueOptions, Inc., a Beacon Health Options company
ValueOptions, Inc., a Beacon Health Options company
BHS - Senior Claims Auditor and Compliance Specialist
ValueOptions is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled.
Position Location: MA - Woburn
AAP Reporting Location:
ID: 33178
Job Family: Claims
Functional Area: CLAIMS
FTE Status:
Scheduled Weekly Work Hrs: 40
Workday Schedule: Weekdays Only
Workday Start Time: 8:30
Workday End Time: 5:00
Variable Work Schedule:
Beacon Health Options is hiring a Senior Claims Auditor and Compliance Specialist to join our growing team in Woburn, MA.
The Senior Claims Auditor & Compliance Specialist will conduct internal audits and plan audits, fraud and abuse prevention and investigation as well as following up on outstanding complex healthcare claims issues. S/he will work closely with the Assistant Vice President (AVP) of Claims Operations to ensure policies and procedures regarding internal Auditing and Fraud & Abuse are adhered to; as well as produce daily and monthly reports. S/he will assists with completion and auditing of reconsideration process.
Responsibilities:
Participate in internal audits to ensure all healthcare claims are adjudicated in accordance with Plan, State and Federal regulations and adjudication logic.
Leads Plan Audits and Plan HEDIS Roadmap 1A deliverables.
Participates in SOC Audit
Responsible for maintenance of all healthcare claims letters and correspondence being compliant and configured.
Responsible for maintenance/update of Medicare / Medicaid / Other language on healthcare claims policies and procedures and helping to create new ones based on plan request/regulations.
Conducts healthcare claims investigations to insure proper healthcare billing practices from contracted and non-contracted providers.
Participates in Fraud & Abuse committee meetings
Ensure reprocessing of incorrectly paid healthcare claims.
Research and investigates reconsiderations and appeals.
Provide daily and monthly reports to Claims AVP.
Keeps AVP of Claims, Manager of Claims and Team Lead informed of issues as they arise.
Assist in training new staff
Other job duties as assigned
Requirements:
Bachelor's degree in accounting, finance, management or related field.
3-5 years of related work experience including but not limited to healthcare claims audit and healthcare claims analysis.
Preferred certification in at least one of the following: CPC, COC and/or certification in Auditing.
High proficiency in Microsoft Excel.
Excellent analytical skills.
Able to communicate effectively with all levels of staff.
PI91495930Estimated Salary: $20 to $28 per hour based on qualifications.
ValueOptions, Inc., a Beacon Health Options company
ValueOptions, Inc., a Beacon Health Options company
BHS - Senior Claims Auditor and Compliance Specialist
ValueOptions is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled.
Position Location: MA - Woburn
AAP Reporting Location:
ID: 33178
Job Family: Claims
Functional Area: CLAIMS
FTE Status:
Scheduled Weekly Work Hrs: 40
Workday Schedule: Weekdays Only
Workday Start Time: 8:30
Workday End Time: 5:00
Variable Work Schedule:
Beacon Health Options is hiring a Senior Claims Auditor and Compliance Specialist to join our growing team in Woburn, MA.
The Senior Claims Auditor & Compliance Specialist will conduct internal audits and plan audits, fraud and abuse prevention and investigation as well as following up on outstanding complex healthcare claims issues. S/he will work closely with the Assistant Vice President (AVP) of Claims Operations to ensure policies and procedures regarding internal Auditing and Fraud & Abuse are adhered to; as well as produce daily and monthly reports. S/he will assists with completion and auditing of reconsideration process.
Responsibilities:
Participate in internal audits to ensure all healthcare claims are adjudicated in accordance with Plan, State and Federal regulations and adjudication logic.
Leads Plan Audits and Plan HEDIS Roadmap 1A deliverables.
Participates in SOC Audit
Responsible for maintenance of all healthcare claims letters and correspondence being compliant and configured.
Responsible for maintenance/update of Medicare / Medicaid / Other language on healthcare claims policies and procedures and helping to create new ones based on plan request/regulations.
Conducts healthcare claims investigations to insure proper healthcare billing practices from contracted and non-contracted providers.
Participates in Fraud & Abuse committee meetings
Ensure reprocessing of incorrectly paid healthcare claims.
Research and investigates reconsiderations and appeals.
Provide daily and monthly reports to Claims AVP.
Keeps AVP of Claims, Manager of Claims and Team Lead informed of issues as they arise.
Assist in training new staff
Other job duties as assigned
Requirements:
Bachelor's degree in accounting, finance, management or related field.
3-5 years of related work experience including but not limited to healthcare claims audit and healthcare claims analysis.
Preferred certification in at least one of the following: CPC, COC and/or certification in Auditing.
High proficiency in Microsoft Excel.
Excellent analytical skills.
Able to communicate effectively with all levels of staff.
PI91495930Estimated Salary: $20 to $28 per hour based on qualifications.
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