Plan Operations Audit Specialist

Plan Operation Audit Specialist

WelbeHealth is a value-based healthcare organization thats transforming the future of senior care by providing an all-inclusive care option to our most vulnerable senior population. We step in as the care provider and care planner that work to keep our participants within their communities out of institutions and cared for like family all while receiving the healthcare and social services needed to thrive.

The Plan Operations Audit Specialist will be accountable for validating various system configurations to ensure accurate processing of claims in accordance with provider agreements regulatory guidelines and company policy. The Plan Operations Audit Specialist will assist with the oversight monitoring and auditing of other functional areas within Health Plan Services including Claims Contracting Credentialing and Provider Partnership.

Essential Job Duties:

• Monitor and validate participant eligibility updates and provider terminations to ensure timely updates to claims processing system
• Review performance of claims functions pertaining to claims processing and provider disputes in order to complete monthly audits and quarterly reporting
• Participate in annual plan operations audit to eliminate deficiencies and stay compliant from a contract and regulatory perspective
• Perform audits of provider Medicare/Medicaid/Medi-Cal enrollment credentialing and network adequacy
• Regularly provide feedback and detailed documentation of audit findings to Plan Operations leadership regarding configuration errors and identify quality improvement opportunities when applicable
• Assist with the adjustment of audit tools to keep audit processes current

Job Requirements:

• Bachelors degree in relevant field; professional experience may be substituted
• Minimum of five (5) years of experience in healthcare claims electronic processing system
• Minimum of two (2) years of experience with compliance and regulatory audits
• Experience working with CMS and Medi-Cal based health plan operations
• Strong comprehension of provider contracts and agreements as it relates to claim reimbursement
• Proficient experience with all Microsoft Suite applications
• Working knowledge of the health plan insurance industry CPT/HCPCS procedure codes ICD-10 codes and relevant federal and state regulations

Benefits of Working at WelbeHealth Apply your expertise in new ways as we rapidly expand. You will have the opportunity to design the way we work in the context of an encouraging and loving environment where every person feels uniquely cared for.

• BENEFITS: Health Coverage on Day 1 Paid Parental Leave 401K Match.
• PERKS: 17 days of paid time off in year one 12 company holidays and 6 sick days
• GROWTH:Career path advancement and leadership opportunities

COVID-19 Vaccination Policy

At WelbeHealth our mission is to unlock the full potential of our vulnerable seniors. In this spirit please note that we have a vaccination policy for all our employees and proof of vaccination or a vaccine declination form will be required prior to employment. WelbeHealth maintains required infection control and PPE standards and has requirements relevant to all team members regarding vaccinations.

Our Commitment to Diversity Equity and Inclusion

At WelbeHealth we embrace and cherish the diversity of our team members and were committed to building a culture of inclusion and belonging. Were proud to be an equal opportunity employer. People seeking employment at WelbeHealth are considered without regard to race color religion sex gender gender identity gender expression sexual orientation marital or veteran status age national origin ancestry citizenship physical or mental disability medical condition genetic information or characteristics (or those of a family member) pregnancy or other status protected by applicable law.

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