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Claims Quality & Audit Program Manager
Location:
Brookfield, WI
Description:
Claims Quality & Audit Program Manager About us Common Ground Healthcare Cooperative is a "who" not a "what." As a cooperative, we are thousands of Wisconsin residents buying health insurance together, supported by a staff focused on providing the best possible service to our members. We are a not-for-profit cooperative, governed by a Board of Directors made up of members who purchase our health insurance. Any earnings are returned to our members in the form of lower prices and better services. Our Culture We are here because we can make a difference in the lives of others. We believe that serving our community is meaningful work and we hold it in the highest regard. We are vibrant, dynamic, and value-focused individuals who welcome different points of view, perspectives, and thoughtful solutions to challenges. We encourage teamwork, integrity, mutual respect, honesty and doing the right thing. We know the importance of showing appreciation for a job well done, celebrate our achievements, and make room for fun and laughter in the workplace. Our Job We are continuously improving our efforts to serve our members and lower their overall healthcare cost through our three key pillars: Advocacy - Partnership - Innovation. Does this sound like a culture you'd like to be a part of? Come join a fun team of committed professionals! How You'll Make a Difference The Claims Quality and Audit Program Manager is responsible for executing the claim investigation and recovery strategy which includes the analysis of claims data for identifying cost containment opportunities both with internal and external partners. The Claims Quality and Audit Program Manager also works to review and analyze recommendations from audits, financial forecasting, and cost containment vendors. This role is responsible for analyzing claims, benefit, configuration, and payment terms data to identify opportunities to ensure proper overall claims processing and payments as well as conducting in-depth simple to complex claims audits and communicating results to front line staff. The Claims Quality and Audit Program Manager will lead the efforts of ensuring quality work is obtained and work with the leadership team to develop standard processes, procedures, and key performance indicators. Additional responsibilities will include analytical research, adhering to "Member First" quality metrics, issue identifications and trends to identify training/education needs within the department. Along with process improvement. Utilize Your Skills By: Investigate, analyze, recover, and resolve various types of claims payment accuracy opportunities and solutions. Collaborate with staff from various departments as well as external clients to ensure prompt and appropriate action is taken regarding cost avoidance/cost containment activities. Organizes, manages, and performs the audit process and ensures adherence to Company, state, federal, reimbursement and contract policies. Serves as subject matter resource to team members, supervisor, and management staff. Monitors and stays current with CGHC benefits and policy language. Responsible for reporting of quality and/or auditing metrics Ensure new plans and updates to existing plans are configured accurately per members certificate of coverage and summary of benefits and that the core processing system is set up to process members claims accurately. Design, develop and execute SQL queries to determine where opportunities exist. Develop analytics to identify and correct aberrant payments. Perform ad hoc analysis on medical expense trends and questions. Audit contracts to determine accuracy and validity of claims systems compared to agreements. Work with contracting and configuration teams when inconsistencies are found. Audit system configurations including: Benefit Class, Code Set Configuration, Step Down Configuration, and Frequency Configuration. Audit remark codes configuration for accurate information Define and document configuration for accurate business functions. Tracks and reports configuration accuracy and other key performance indicators. Partner with Provider Relations, Reporting, Medical Management, Actuarial and IT claims configuration for the identification and implementation of payment improvements. Review and critique testing of new/updated configurations to the system. Prepare clear, fact-based, and well-organized observations/reports and supporting work papers that reflect the audit finding work performed and effectively support the conclusions reached. Collaborates with the Manager, subject matter experts, peers, and other appropriate staff to design and develop audit feedback and enhanced training criteria . Delivers information and leads structured learning activities while facilitating participant interactions to achieve the session objectives. Demonstrates an ability to overcome occasional difficult interactions providing essential feedback and ensuring all identified staff engage in learning and improved quality outcomes. Create trend analysis metrics in a spreadsheet format. Acts as a liaison between departmental end-users and ISBA resources in the analysis, design, configuration, testing and maintenance of systems to ensure optimal operational performance. Any other tasks or duty as assigned or required. What You'll Need to Bring: Bachelor's Degree in Health Care Administration, Business Administration, or a related field (4 additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a bachelor's degree). 5+ years of experience in health insurance claim payment methodologies. 5+ years health insurance experience and/or health program experience, preferably including commercial individual, commercial group, and Marketplace insurance. 5+ year of medical claims configuration, testing and processing experience required. Knowledge of SQL Server 2 years' experience with auditing in healthcare/health insurance Strong process improvement skills with proven ability to manage multiple tasks and Strong communication skills, both verbal and written, and the ability to communicate and present effectively with all levels and all departments. Strong technical aptitude Medical coding experience preferred. Ability to build relationships within the business units. Outstanding verbal and written communication skills in relaying positive and constructive feedback to develop high performing associates. Ability to identify and resolve customer issues by utilizing excellent product and process knowledge. Must use good judgment and critical thinking skills for the ability to act decisively. Ability to recommend and implement improvements in procedures, materials, and products to prevent future member or other stakeholder concerns. Highly proficient with Microsoft products such as Outlook, Teams, Excel, Word, and PowerPoint. Strong analytical thinking and problem-solving skills Proven ability to take initiative; proactive and able to work independently. General Requirements: Maintains attendance according to Company standards Adheres to Company policies and procedures Ability to treat others with dignity, respect, and courtesy Ability to maintain patient, employee, and proprietary confidentiality Ability to communicate effectively in-person and in all forms of communication Ability to plan, organize, analyze, problem solve, coach, facilitate and adapt Ability to provide professional image and act professionally Ability to be flexible and adapt to changing situations We've Got You Covered CGHC offers a comprehensive benefit package and broad range of programs to meet the needs of our employees to help protect your health, wealth, and future. Job Posted by ApplicantPro
Company:
Common Ground Healthcare Cooperative
Posted:
January 25 on ApplicantList
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More About this Listing: Claims Quality & Audit Program Manager
Claims Quality & Audit Program Manager is a Executive Program Manager Job at Common Ground Healthcare Cooperative located in Brookfield WI. Find other listings like Claims Quality & Audit Program Manager by searching Oodle for Executive Program Manager Jobs.
Claims Quality & Audit Program Manager is a Executive Program Manager Job at Common Ground Healthcare Cooperative located in Brookfield WI. Find other listings like Claims Quality & Audit Program Manager by searching Oodle for Executive Program Manager Jobs.