Senior Auditor – Dynamic Audit Resourcing Team
Capital One
Senior Compliance Claims Auditor, Data
Collective Health
full-time
Posted on:
Location Type: Hybrid
Location: San Francisco • Arizona, California, Colorado, Connecticut, Florida, Illinois, Maryland, Massachusetts, Minnesota, Missouri, Nevada, New Jersey, New York, North Carolina, Ohio, Oregon, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin • 🇺🇸 United States
Visit company websiteSalary
💰 $107,635 - $168,750 per year
Job Level
Senior
About the role
- Create electronic claims accuracy monitoring mechanisms utilizing claims data models to identify potentially non-compliant claim adjudications.
- Develop and implement automated claims audits utilizing purposeful review of claims patterns and data analytics to proactively identify adjudication inaccuracies.
- Work cross-functionally with data analytics, data engineering, and other operational teams to identify and remediate claims errors based on data patterns.
- Audit medical claims received from providers for adjudication accuracy, including professional and institutional claims.
- Manage internal and external audits.
- Provide timely input on compliance-related issues and guidance requests.
- Assist with compliance risk assessments and audit readiness.
- Assist with new compliance regulation implementation related to claims accuracy.
- Collaborate with team members to identify and mitigate compliance risk for claims.
- Work closely with Collective Health attorneys to receive and coordinate legal guidance needed to operationalize important initiatives and requirements.
Requirements
- Bachelor's degree or equivalency required, preferably in a business, technology, or healthcare field.
- At least 8 years of experience performing data analyses on complex medical claims data sets.
- A coding credential is required, preferably AHIMA CCS, or CPC, CPC-A, RHIT.
- Broad experience and knowledge of coding and reimbursement systems (MS-DRGs, PPS Systems, bundled payments, OPPS, value-based care, FFS).
- Broad experience and knowledge of healthcare and healthcare business practices and principles.
- Broad experience and knowledge of third-party payer practices, including precertification, timely filing, claims processing, coverage, and payer rules.
- Broad experience and knowledge of healthcare claims data and analytics.
- Knowledge and applicable understanding of federal laws related to ERISA group health plans and state department of insurance laws.
- Knowledge of the 5010 data standards, along with practical understanding of EDI transmission files (835/837, 270/271, etc.) and all X12 data specifications.
- Knowledge and applicable understanding of subrogation, coordination of benefits, and claims hierarchy standards.
- Knowledge and applicable understanding of state and federal laws which apply to claims processing for group health plans.
- Experience developing or enhancing a compliance program is desired.
- A CHC certification is preferable.
- Proven ability to build relationships and to collaborate effectively with a broad range of stakeholders and departments.
- Strong organizational and project management skills with demonstrated attention to detail.
- Proficiency with technology tools, including Google Drive, Sheets, Docs, Box, Smartsheet, Looker, Slack, and Databricks.
- Critical thinking and decision-making skills, with the ability to quickly determine issues that need escalation.
- Excellent written and verbal communication skills (including presentations) and the ability to drive execution in a team environment.
Benefits
- Stock options
- Health insurance
- 401k
- Paid time off
- Flexible work arrangements
- Professional development opportunities
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
data analysisclaims auditingcompliance risk assessmentcoding systemsreimbursement systemshealthcare claims datadata analyticscompliance program developmentclaims processingfederal laws related to ERISA
Soft skills
relationship buildingcollaborationorganizational skillsproject managementattention to detailcritical thinkingdecision-makingcommunication skills
Certifications
AHIMA CCSCPCCPC-ARHITCHC
