Claims Quality Auditor

Overview

Are you looking for a purposeful career that will make a difference in the patient community? At CCS, our approach to at-home patient care is redefining chronic care management. We are seeking individuals that will thrive in a patient-centric dynamic environment. If you are an attentive listener, fast-thinker, and problem-solver, with the ability to relate to different people, you are a match for CCS.

The successful candidate will report directly to the VP, Compliance

Responsibilities

• Coordinates and participates in implementing programs, policies, and practices to ensure that all operating units in the company are in full compliance with State and Federal Healthcare laws as well as payer guidelines

• Maintains an up-to-date familiarity with payor specific guidelines and requirements to ensure CCS Medical's continued compliance

• Initiates and conducts periodic focused audits and develops systems to measure compliance

• Conducts periodic internal audits of claim submissions and supporting documentation including preparation and maintenance of internal audit file

• Ability to train staff on workflow processes and procedures

• Responds to external audit requests for documentation to support claim submissions

• Prepares reports containing the results of internal audits and assists in the presentation of recommendations or modifications on business processes to Operations Management

• Fields questions from internal sources regarding insurance guidelines and requirements as well as State and Federal guidelines

• Prepares and maintains metric reporting for the assigned team

• Cultivates and maintains a solid understanding of State and Federal Healthcare laws including but not limited to the False Claims Act, the Anti-Kickback Statute and the Medicare Supplier Standards

• Responds to Compliance Management research requests as needed and reports findings to CCS Medical Compliance Management and department upon completion of research

• Research topics of interest in various media sources to determine compliance trends and their effect on CCS Medical and provide findings to Compliance Management. Pulls documentation and provides other assistance in preparation for onsite payer and/or vendor audits

• Always maintains a high degree of confidentiality due to access to sensitive information

• Maintains regular, predictable, consistent attendance and is flexible to meet the needs of the department

• Follows all Medicare, Medicaid, HIPAA, and Private Insurance regulations and requirements

• Abides by all regulations, policies, procedures and standards

• Participates in on-going training with internal departments to ensure familiarity with their processes

Desired Outcomes

• Meets all productivity requirements

• Maintains positive internal and external customer service relationships

• Maintains open lines of communication

• Plans and organizes work effectively for team assignments and ensures its completion

• Demonstrates team behavior and promotes a team-oriented environment

• Actively participates in Continuous Quality Improvement

• Always represents the organization professionally

Qualifications

Position Requirements:

• Associate degree (AA) or equivalent from a two-year college or technical school preferred and three to five years Compliance or Revenue Cycle related experience or equivalent combination of education and/or experience

• Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, or government regulation documents and apply that information to job functions

• Highly organized with strong attention to detail required

• Excellent written and oral communication skills

• Ability to create and maintain detailed Excel spreadsheets (including adding formulas, sorting, formatting, etc.)

• Ability to write clear and understandable reports and business correspondence

• Experience conducting research online and through other mediums

• Proficient in problem solving, creativity, independent thought, and sound judgment

• Ability to effectively present information and respond to questions regarding the information presented

• Ability to add, subtract, multiply and divide all units of measure using whole numbers, common fractions, and decimals, including ability to compute rate, ratio, and percent and to draw and interpret bar graphs

• Ability to define problems, collect data, establish facts, and draw valid conclusions

• Proficient with Microsoft Office

Values

Values

Certainty-The lives of the individuals we serve depend on our ability to execute. We commit to doing this every day.

• Use appropriate methods and a flexible interpersonal style to help build a cohesive and collaborative team based on a foundation of trust and transparency. Deliver what you commit to.

Compassion-We understand the burdens of patients and their loved ones and channel this into a relentless pursuit of customer satisfaction in every part of our business.

• Ensure that the patient is the driving force behind business decisions, implementing service practices that meet needs of both the patient and the organization. Treat other the way you want to be treated.

Advancement-We are endlessly looking for ways to progress and become more innovative in all things we do.

• Encourage innovative approaches for addressing opportunities and facilitating change, driving cross-functional alignment to accomplish goals. Speak the truth.