Claims Audit Analyst - Denver Health Medical Plan (Must Live in Colorado. Weekly On-Site Requirement)

Benefits

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We are recruiting for a mission-driven Claims Audit Analyst - Denver Health Medical Plan (Must Live in Colorado. Weekly On-Site Requirement) to join our team! We're with you for life's journey. At Denver Health, purpose isn't just something we believe in-it's something we live every day, for life's journey. Our Values Respect | Belonging | Accountability | Transparency Department Managed Care Administration * Must Live in Colorado * This is a hybrid role located in Denver, Colorado with a requirement of being in the office 2 days per week. Job Summary Under general supervision, Claims Audit Analyst is responsible for benefit administration and assist with the daily management of claims inventory. Daily data analysis and research of claims processing to ensure benefit structures and operation processes are adhering to the rules, regulations and contractual requirements by CMS, DOI, contracted and non- contracted providers. Oversee the daily management of claims inventory through Business Management Services (BMS) for issue escalations or resolutions. Serves as liaison between users of the software and technical staff (BMS and IS). Work in conjunction with the Compliance program to monitor and detect potential claims for fraud and abuse. This position will interact will all levels of management and employees. Essential Functions : - Accurately perform audits on claims processed by the vendor. Perform special claims audits as assigned. Perform calibration "audit the auditor" assessments and share findings. 30% -Review provider escalations and ad-hoc member/provider grievance and appeal reviews to address possible payment errors. Escalate any needed configuration changes. 20% -Monitor member accumulators and log on Smartsheet any overage to Member Maximum Out of Pocket limits. Work with vendor to root cause & resolution 10% -Address specific pricing needs including but not limited to: transplant pricing, DRG downcoding, NSA claims. 10% -Review IDR NSA disputes, conduct greater of QPA reviews, log cases to Smartsheet, offer in compromise, route any arbitration cases for further assessment/completion. 10% -Conduct weekly check run reviews for abnormalities for all plans based on summary reports to ensure that claim payments are adhering to the rules, regulations and contractual requirements. 10% -Ad hoc work as required, including supporting the Claims Manager with data and analysis. 10% Education : Bachelor's Degree required OR High school diploma or GED required AND an additional 4-6 years of claims experience in lieu of degree required Work Experience : 1-3 years claims experience required OR 7-9 years claims experience without Bachelor's degree required Licenses : Knowledge, Skills and Abilities : Thorough knowledge of QNXT and benefit structure to ensure claims accuracy. Ability to define problems, collect data, establish facts and draw valid conclusions. Knowledge of all claim forms and coding types, including UB-04, CMS1500, ICD-9-CM, CPT-4, ICD-10-CM, HCPC, Revenue and NOC coding. HIPPA, HEDIS. Experience with Medicare, Medicaid and Commercial programs preferred. Extensive knowledge of claims administration in a healthcare field. Ability to lead/manage projects and interact with staff on all levels. Able to implement testing material for changes with benefit structures for all lines of business. Interact and collaborate with other corporate groups such as Provider Relations, Member Services, Information Systems, Compliance, Third Party Recovery, Finance, Patient Accounts, Enrollment, Utilization Management and Product Line Managers. Key candidate will be adaptable; detailed oriented and have strong analytical skills. Excellent verbal and written communication skills. Access database, Reports, Queue's and other tools as needed. Total Claims Capture and Control (TC3) experience preferred. Working knowledge of CMS/Medicare payment platforms a plus including the Resource Based Relative Value System (RBRVS) and Diagnostic Related Groups (DRG). Proficiency in Word, Excel, Webstrat, PowerPoint, Business Intelligence Portals and Audit Tool. * Must Live in Colorado * This is a hybrid role located in Denver, Colorado with a requirement of being in the office 2 days per week. Shift Days (United States of America) Work Type Regular Salary $60,500.00 - $87,700.00 / yr

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