Healthfirst

This position is 100% Remote.
 

Scope of Responsibilities:

• Conduct moderately complex to complex quality audits of provider claims, pre-payments and post-payments including high-dollar and specialized claims across multiple lines of business, claim types and products.

• Audit the work of more junior auditors and identify opportunities for coaching and//or training.

• Identify and communicate issues identified through audits and recommended solutions relevant to business operations.

• Assist management in preparing departmental reports policies and procedures.

• Mentor and coach Financial and//or Operations QA auditors.

• Participate as a Subject Matter Expert on various process improvement projects designed to meet departmental and operational needs.

• Assist with performing User Acceptance Testing (UAT) on system enhancements or corporate projects in partnership with Business Operations

• Analyze errors and determine root causes for appropriate classification.

• Record//track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure the quality of the network.

• Review and investigate claims and encounters for medical, facility, pharmacy, dental and vision services including contractual provisions, authorizations and Healthfirst policy and procedure.

• Prepare written reports concerning investigation activities and present results of investigations to senior staff.

• Complete subsequent auditing and handling of specific claims and appeal requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.

• Review the accuracy and efficiency of existing training materials.

  Minimum Qualifications:

  • Audit experience with the investigation, determination and reporting of financial processes

  • Work experience in Microsoft Office suite of applications including advanced Excel (formatting formulas, managing data, filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations)

  • Experience conducting root cause analysis in an auditing capacity

  • Experience conducting analytical work and providing creative ideas for problem solving

  • Work experience requires written and verbal communication that is clear, concise, grammatically correct, and professional

  • Experience handling confidential information

  • Associate degree from an accredited institution

    
    Preferred Qualifications:

    • Bachelor’s degree from an accredited institution

    • Audit experience with the investigation, determination and reporting of financial processes specifically around Healthcare Claims Adjudication and Claims Processing

    • Ability and willingness to handle increasing workload and responsibility

    • Willingness and ability to learn and evaluate new information, both technical and procedural

    • ICD10 certification

    • Basic foundation of SQL, Tableau, and SharePoint

    • Knowledge of at least two or more lines of business such as NY Medicare, Medicaid, Family Health Plus, Child Health Plus