Astrana Health

Senior Manager – Claims Delegation Audit

Astrana Health

full-time

Posted on:

Location Type: Hybrid

Location: Monterey Park • California • United States

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Salary

💰 $115,440 - $148,148 per year

Job Level

Senior

About the role

  • The Senior Claims Manager, Claims Delegation Oversight, is responsible for the management and oversight of all Claims Delegation Audits, including health plan and governing agencies audits, i.e., DMHC, CMS, and DHCS.
  • This role will be responsible for the development and execution of department strategies, overall Audit program, Audit process optimization, and management, identifying and leveraging technology and data to improve the quality and minimizing process cost of Claims.
  • The position alongside the leadership team will contribute to driving strategic planning, operational excellence, and accuracy of the claims process and ensure compliance with regulations and contract requirements for Medicare, Commercial Exchange, and Medicaid service lines.
  • This position will contribute and influence overall Claims Delegation Oversight roadmap to ensure Claims Administrations are adhering to regulatory and internal guidelines as they apply to claims processing and adjudication.
  • Working with the Department Director, Senior Manger will collaborate with other Astrana Health departments and personnel to develop strategies to identify, mitigate and optimize operational and financial gaps.

Requirements

  • Solid understanding of the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) rules and regulations governing claims adjudication practices and procedures required
  • Detail knowledge and understanding of Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi-Cal fee schedule, All Patient Refined Diagnosis Related Groups (AP-DRG), Ambulatory Payment Classifications (APC), etc
  • Detail knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
  • Possess working knowledge of NCQA, DHS, and HCFA standards
  • Knowledge of medical terminology combined with detailed knowledge and experience with CPT, HCPCS, DRG, REV, OPS, ASC, ICD10, CRVS, RBRVS, CMS, ICE for Health Plan, DMHC and DHS fee schedules and CMS Medicare regulatory agencies, COB and Third-Party Liability recovery
  • Ability to coach and motivate employees to reach and sustain established performance standards and goals
  • Ability to direct the work of others and mediate interpersonal encounters with tact and diplomacy, complying with legal guidelines and company policy
  • Must have hands-on claims auditing experience with a clear root cause and prevention plan management
  • Must have the ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC Regulations
  • Must possess the ability to effectively present information and respond to questions from managers, employees, customers
  • Must possess advanced reasoning and problem-solving abilities and planning skills
  • Ability to multi-task, prioritize and work in a fast-paced environment under minimal supervision
  • Proficiency in Excel including the ability to create and revise Excel spreadsheets to provide accurate and clear reports
  • Bachelor of Science (BS)/Bachelor of Arts (BA) or equivalent education and experience required
  • 3+ years of claims administration experience in a Health Plan/IPA/MSO setting
  • 3+ years of experience with Health Plan Audits Delegation Audit functions and oversight
  • Proven success in improving key performance metrics, including process improvement, cost reduction, and improved efficiency
  • Demonstrated leadership skills, ability to coach, mentor, and foster a culture of achievement
  • Strong independent decision-making, influencing, and analytical skills
  • Extensive knowledge of claims processing guidelines, including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines
Benefits
  • Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis if you live within 35 miles. The office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754
  • The national target pay range for this role is $115,440.56 - $148,148.72. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.
  • Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action Employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.
  • Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
claims auditingclaims processingdata analysisprocess optimizationmedical terminologyCPTHCPCSICD10RBRVSAP-DRG
Soft Skills
coachingmotivatinginterpersonal skillsproblem-solvingplanningmulti-taskingprioritizationindependent decision-makinginfluencinganalytical skills