What are the responsibilities and job description for the Director of Claims Audits position at All Care To You?
About Us
All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick time, and vacation time as well as a 401k plan. Additional employee paid coverage options available.
Job purpose
The Claims Audit Director is responsible for auditing institutional and/or professional claims according to established policies and procedures.
Duties and responsibilities
- Institutional Claims Report Review
- Institutional full medical record review with no DRG change
- Institutional full medical record review with DRG change and letter of explanation
- Professional Claims Report
- Professional Claims Review with Records
- Symkey Review and Support
Qualifications
- 10 years or more experience in processing HMO claims in a managed care environment.
- Proficient in Medical Record Review as it pertains to ICD10 coding.
- Proficient in rate application for outpatient PPS & Inpatient DRG facility, ASC, APC, Interim Rate Payment methods to applicable lines of business. (Medicare, Commercial, Medi-Cal).
- Familiar with all regulatory requirements including CMS, DMHC and DHS.
- Proficient with all Federal and state requirements in claim processing.
- Knowledge of medical terminology and coding.
- Recognize the difference between Shared Risk and Full Risk claims.
- Proficient in applying Division of Financial Responsibility.
- Knowledgeable in applying Health Plan Benefit Matrices.
- Proficient understanding of AB1324.
- Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations.
- Excellent communication skills including reports, correspondence, and verbal communications.
- Demonstrated proficiency with Microsoft Word and Excel.