Delegation Oversight Claims Auditor

Location: Remote-US, California US

Notice

This position is no longer open.

Job Number: 3873

Workplace Type: Fully Remote

Position Title: Claims Delegation Oversight Auditor

External Description:

Position Summary:

The Delegation Oversight Claims Auditor (DOAC) reports directly to the Claims Delegation Oversight Manager (CDOM). Plans and conducts audits of Alignment’s contracted entities delegated for Medicare Advantage claims processing. Promote and maintain a positive working partnership with the delegated entities. Ensure adherence of Federal and/or State claims requirements, and other claims standards. Coordinates and leads all delegated claims audits.

 

General Duties/Responsibilities (May include but are not limited to):

Conduct annual risk assessment of delegated entities; develop the delegated entity claims annual audit plan
Schedule and maintain the claims audit schedule
Conduct audit of case file samples and other supporting documentation against CMS, claims processing standards, and other established criteria
Analyze audit results and produce a complete and concise audit report
· Issue corrective action requests where required

· Ensure corrective action plan responses are properly developed and follow-up items are completed according to agreed-upon deadlines.

· Conduct validation audits as needed.

Review audit finding trends to identify training opportunities; collaborate with the DO Manager to draft training documents for distribution
Create and maintain accurate, complete, and current audit records
Participate in CMS and/or other regulatory audits as needed
Supervisory responsibilities:

N/A

 

Minimum Requirements:

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.

 

· Minimum Experience:

a. 5 + years of claims processing or claim management experience in a Medicare Advantage Health Plan or Medical Group/IPA setting.

b. 2 + years experience in a delegation oversight role in a Medicare Advantage Health Plan.

c. Possess in-depth knowledge of managed care operations, with emphasis on claims processing functions.

d. Comprehensive knowledge and experience with CMS compliance reporting, i.e., Part C ODR, ODAG, Monthly Timeliness, etc.

· Education/Licensure:

a. Requires a high school diploma (Associate or bachelor’s degree in a related area is preferred)

· Other:

a. Knowledge of Medicare Advantage audit processes and applicable state and federal regulations.

b. Must possess a high level of organization skills to maintain accurate records and documentation.

c. Attention to detail with analytical and problem-solving capabilities

d. Ability to take initiative and see tasks to completion

e. Excellent verbal and written communication skills

f. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPPA) regulations

g. Ability to establish and maintain positive and effective work relationships with

delegated entities.

h. Ability to scope and identify potential issues and escalate accordingly

i. Mathematical Skills: Ability to calculate figures and amounts such as discounts, interest, proportions and percentages. Ability to apply concepts of basic algebra.

j. Excellent computer skills with a strong proficiency in Excel, Word, SharePoint, PowerPoint.

k. Other Skills and Abilities:

i. Excellent verbal and written skills

ii. Knowledge of medical terminology

iii. Familiarity with various claims processing systems is a plus

iv. Knowledge of claims coding, CPT, ICD-10, HCPCS or other coding

v. Strong knowledge of CMS, Federal and State regulatory claims requirements

City: Remote-US

State: California

Location City: Remote-US

Location State: California

Community / Marketing Title: Delegation Oversight Claims Auditor

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].