Senior Claims Audit & Compliance Leader

Providence; Mission Hills (CA); On-site; USD 120,000 - 150,000; Full time

Job summary

Join Providence Medical Foundation to contribute to patient-focused care, culture, and continuous improvement in claims operations, policy implementation, and regulatory compliance across the organization.

Qualifications

• 5 years professional and facility claims processing experience.

Responsibilities

• Manage the claims internal audit functions, including audit processes for adjudicated claims and encounters.
• Monitor check run processes for accuracy.
• Develop policies and procedures for periodic claims audits and ensure compliance with affiliated health plans, client groups, and administrative contractual agreements.
• Design, plan, direct and implement claims training programs for the organization, including adaptations to changes in policies, procedures and technologies.
• Must be familiar with applicable State and Federal claim payment and denial timeliness legislation.
• Must be familiar with Timeliness Compliance pursuant to State and Federal rules and regulations.
• Must be well versed regarding the Provider Dispute Resolution tracking mechanism (AB1455).

Skills

Claims processing

Auditing

Policy development

Training programs

Regulatory compliance

Job description

Join Providence Medical Foundation to contribute to patient-focused care, culture, and continuous improvement in claims operations, policy implementation, and regulatory compliance across the organization.