MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree, or greater in related Healthcare field.

EXPERIENCE:

1. Two (2) years of experience working with audits in a health care capacity.

2. Five (5) years of medical and pharmacy claims and adjustment processing experience.

3. One (1) year of provider/member file maintenance experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Master's Degree, or equivalent experience, in related healthcare field.

EXPERIENCE:

1. Seven (7) or more years in a medical and pharmacy claims processing and audit environment.

2. Three (3) or more years with audit or quality control oversight.

3. Three (3) or more years of mentoring and/or training experience.

4. Two (2) or more years of formal audit response experience. (CMS, SOX, etc.)

5. Two (2) or more years of familiarity with member and provider contract structure and file maintenance.

6. At least one (1) or more years of quality report creation and implementation experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Creates and conducts regularly scheduled audits of claims team processes and outputs.

2. Creates and conducts regularly scheduled audits of claims team adherence to production metrics.

3. Assesses claims staff production and quality within department standards.

4. Creates, Implements, and Presents audit reports on the compliance of claims processing guidelines.

5. Effectively communicates with internal and external staff.

6. Elevates issues to next level of supervision and Compliance, as appropriate.

7. Develops and conducts staff training on any audit issues as needed.

8. Attends all required training classes, demonstrating proficiency and high ability to learn.

9. Other duties as deemed appropriate by the Management Team.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to sit for extended periods of time.

2. Ability to answer phone calls for extended periods of time.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment with electrical equipment (i.e., telephone, personal computer, copier, fax machines, etc.)

2. Computer Software/Systems include but not limited to Microsoft Office Professional Suite (Outlook, Word, Excel, Access) Internet Explorer and EPIC

SKILLS AND ABILITIES:

1. Working Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.

2. Ability to take direction and to navigate through multiple systems simultaneously.

3. Excellent written and oral communication, interpersonal skills, and telephone etiquette.

4. Ability and patience to provide coaching and training to claims processing staff.

5. Ability to keep precise, detailed reports on audit and training activity.

6. Attention to detail and organizational skills.

7. The ability to communicate clearly, concisely, and articulately both in oral and written forms.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center: