Promotes, integrates, implements and oversees the day to day operations involved in the claims compliance and auditing processes.  Responsible for identifying, communicating, and managing all regulatory and health plan compliance requirements and for the development and delivery of periodic reports on the status of compliance.  Coordinates with outside vendors and other internal management peers in the identification and correction of issues identified through internal and health plan audit findings.

Essential Duties and Responsibilities:

• Manages work assignments/duties to ensure smooth interdepartmental operations in the area of claims compliance and auditing. 
• Manage and maintain health plan audit schedules and reports on health plan audit activity to designated MSO and corporate management. 
• Assures appropriate and timely preparation for health plan oversight audits and for delivery of all audit requirements to facilitate the health plan audit process. 
• Manages the process for accurate and timely completion of corrective action plans resulting from health plan audit findings.  Assures that all required corrective action plans are filed timely and that corrective actions outlined in the CAP actually take place. 
• Assures timely and accurate completion and filing of all required regulatory and oversight reporting. 
• Develops and manages appropriate prospective and retrospective auditing processes to assure accurate, compliant processing of claims, disputes, and adjustments.
• Identifies and communicates deficient processing trends and coordinates with outside vendors and internal management to develop appropriate process corrections.
• Create efficiencies with the department through the creation or updating of policies and procedures and workflows.
• Provide both written and verbal direction to all levels of the claims compliance and auditing staff.
• Attends administrative meetings and disseminates information to staff when appropriate.
• Studies and standardizes procedures to improve efficiency of subordinates.
• Maintains harmony among staff and works to resolves staff grievances.

Major Responsibilities:

Manages and provides guidance to department staff to ensure that department standards, organizational procedures and regulatory requirements are met.  Carries out managerial responsibilities in accordance with organization policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints removing obstacles for the staff.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience:

·         Minimum requirement of over 8 years proven supervisory/management experience in Claims Compliance and Auditing

·         High School Diploma or equivalent is required. A BS/BA is preferred

·         Strong knowledge of all claim types and methodologies

·         Experience with managed care/HMO claims processing standards in an IPA, hospital and health plan setting

·         Working knowledge of various provider reimbursement methodologies,

·         Strong knowledge of regulations pertaining to Medicare(CMS), Medi-Cal and commercial (DMHC).  Also requires knowledge of Coordination of Benefits, health plan division of financial responsibility (DOFR), and industry “best practices.” .

·         Good knowledge of PC business applications (MS Word, Excel, PowerPoint, MS Project)