Health Plan Operations Manager (Call Center Audit Lead) LOCALS PREFERRED

Raag Solutions; New York (NY); On-site; USD 70,000 - 110,000; Full time

Job summary

An established industry player is seeking a Health Plan Operations Audit Expert to enhance compliance and operational efficiency within their Medicare/Medicaid offerings. This role demands a seasoned professional with extensive experience in claims management and auditing. You will lead the auditing processes, ensuring regulatory compliance while collaborating with various teams to implement corrective actions. If you are passionate about optimizing health plan operations and ensuring claims accuracy, this position offers an exciting opportunity to make a significant impact in a dynamic environment.

Qualifications

• 5+ years in health plan operations, claims management, or auditing.
• Knowledge of Medicare and Medicaid regulations.

Responsibilities

• Lead claims integrity auditing for Medicare and Medicaid SNP claims.
• Develop audit protocols and conduct regular audits.

Skills

Health Plan Operations

Claims Management

Auditing

Medicare Regulations

Medicaid Regulations

Education

Bachelor's in Healthcare Administration

Master's in related field

Tools

Audit Protocols

Quality Improvement Initiatives

Job description

LOCALS PREFERRED
SHOULD WORK IN W2

• We are seeking a highly skilled and experienced professional to join our team as a Health Plan Operations Audit Expert with a specialization in Call Center and Claims Integrity Auditing for Medicare/Medicaid SNP (Special Needs Plan) claims.
• This role is critical in ensuring compliance with regulatory requirements, maintaining claims accuracy, and optimizing operational efficiency within our organization's health plan offerings.

Qualifications:

• Bachelor's degree in Healthcare Administration, Business Management, Finance, or related field; Master's degree preferred.
• Extensive experience (5+ years) in health plan operations, claims management, or auditing, with a focus on Medicare and Medicaid SNP claims.
• In-depth knowledge of Medicare and Medicaid regulations, policies, and procedures governing claims processing and billing.
• Proven track record of developing and implementing audit protocols, methodologies, and quality improvement initiatives.
• Relevant certifications (e.g., Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), Certified Internal Auditor (CIA)) preferred.

Responsibilities:

Claims Integrity Audit Management:

1. Lead and oversee all aspects of claims integrity auditing processes for Medicare and Medicaid SNP claims.
2. Develop and implement audit protocols, methodologies, and procedures to ensure comprehensive coverage and accuracy assessment.
3. Conduct regular audits of claims data, documentation, and processes to identify discrepancies, errors, and areas for improvement.
4. Collaborate with internal stakeholders, including claims processing teams, compliance officers, and data analysts, to address audit findings and implement corrective actions.

Regulatory Compliance Assurance:

1. Stay updated on Medicare and Medicaid regulations, guidelines, and requirements related to SNP claims processing and billing.
2. Interpret and apply regulatory standards to audit processes and ensure compliance at all stages of claims handling.
3. Provide guidance and support to operational teams to align processes with regulatory expectations and minimize compliance risks.