Sr. Manager Claims Delegation Audit
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Job Location:
Monterey Park, NM - USA
Yearly Salary:
$ 125000 - 140000
Posted on:
6 days ago
Vacancies:
1 Vacancy
Job Summary
The Senior Claims Manager Claims Delegation Oversight is responsible for the management and oversight of all Claims Delegation Audits including health plan and governing agencies audits i.e. DMHC CMS and DHCS. This role will be responsible for the development and execution of department strategies overall Audit program Audit process optimization and management identifying and leveraging technology and data to improve the quality and minimizing process cost of Claims. The position alongside the leadership team will contribute to driving strategic planning operational excellence and accuracy of the claims process and ensure compliance with regulations and contract requirements for Medicare Commercial Exchange and Medicaid service lines.
Our Values:
Our Values:
- Put Patients First
- Empower Entrepreneurial Provider and Care Teams
- Operate with Integrity & Excellence
- Be Innovative
- Work As One Team
What Youll Do
External Audit planning execution & support
- Own the endtoend strategy and execution of all external audits (e.g. CMS DMHC health plan audits) ensuring readiness successful delivery and continuous score improvement
- Lead audit planning preaudit readiness reviews execution issue tracking and final reporting
- Establish and monitor audit metrics scorecards and dashboards; ensure timely accurate communication of results
- Oversee corrective action plan (CAP) management including root cause analysis remediation and prevention strategies
- Partner with Claims Operations to ensure audit findings are remediated promptly and sustainably
Documentation Compliance & Training
- Review and approve auditrelated policies procedures workflows job aids and SOPs for accuracy and regulatory compliance
- Ensure adherence to all legislative regulatory and contractual requirements
- Identify training gaps oversee training strategy and delivery and measure training effectiveness
CrossFunctional Collaboration & Process Improvement
- Collaborate closely with internal partners (Claims UM CM Pharmacy Compliance IT Finance Configuration Network and others) to resolve issues and drive operational excellence
- Partner with IT and Data Analytics to develop and maintain audit tools reports dashboards and scorecards
- Recommend and support system rules and workflow improvements impacting claims adjudication and audit outcomes
- Lead or support special projects including new business implementations business analyses and strategic initiatives
People Leadership
- Set team goals define success metrics and drive accountability
- Recruit develop coach and motivate a highperforming team
- Track performance and guide the team to achieve audit and operational objectives
Other duties as assigned
Qualifications
- Bachelors degree (BA/BS) or equivalent combination of education and experience
- 3 years of claims administration experience within a Health Plan IPA or MSO environment
- 3 years of experience supporting or overseeing health plan and delegation audits
- 3 years of people leadership experience including coaching and performance management
- Handson claims auditing experience including root cause analysis and corrective action management
- Have advanced knowledge of CMS DHCS DMHC Medicare MediCal and Medicaid regulations impacting claims adjudication
- Strong understanding of claims payment methodologies (e.g. RBRVS DRG/APDRG APC Medicare/MediCal fee schedules)
- Proficiency in Excel including creating and maintaining reports and data summaries
- Highly organized adaptable and able to prioritize in a fastpaced environment with minimal supervision
- Proven ability to lead coach and motivate teams toward defined performance goals
- Strong analytical problemsolving and decisionmaking skills
Youre great for the role if
- Masters Degree
- Have experience with claims systems and tools (e.g. EzCap IDX Cotiviti Burgess)
- Familiarity with clearinghouses (e.g. Office Ally) core system implementation and configuration
Environmental Job Requirements and Working Conditions
- Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis if you live within 35 miles. The office is located at 1600 Corporate Center Dr. Monterey Park CA 91754.
- The national target pay range for this role is $125000 - $140000. Actual compensation will be determined based on geographic location (current or future) experience and other job-related factors.
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action Employer. We do not discriminate based upon race religion color national origin gender (including pregnancy childbirth or related medical conditions) sexual orientation gender identity gender expression age status as a protected veteran status as an individual with a disability or other applicable legally protected characteristics. All employment is decided on the basis of qualifications merit and business need. If you require assistance in applying for open positions due to a disability please email us at to request an accommodation.
Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
Required Experience:
Manager
