Claims Audit Specialist (Remote)

LOCATION:  Remote– This is a home based, virtual position that operates within the hours of 8:30am-5:00pm on US Eastern Standard time (EST). Vaya Health welcomes applications from NC, SC, GA, TN, VA, MD, and FL.

GENERAL STATEMENT OF JOB

This position is responsible for identifying and analyzing claims data within a Managed Care Plan.  It requires proactive analytics to assist in quality monitoring on claims processed in the claims adjudication system.   The position provides feedback to department leadership for process improvement.  It requires managing data and information as well as a well-developed understanding of the health insurance industry and an in-depth understanding of healthcare claims data.

Note: This position requires access to, and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

ESSENTIAL JOB FUNCTIONS

Conduct Claim Audits: 

This position will audit a random sample of processed claims to include claims processed by a claims adjudication system as well as claims manually processed by claim representatives. Perform audits to determine whether system controls were effective, efficient, and in compliance with all local, state and federal regulations; proactively identifying risks and issues and developing solutions.  Facilitate the resolution of claims issues through active research and system analysis across multiple operational areas.  Detect claims overpayments due to systemic, billing and/or human errors. Accurately and timely document claims reviews in the audit form according to pre-established parameters and guidelines as defined in the department Standard Operating Procedures (SOPs) and workflows.   Abide by company policy and best practices in the areas of security, with special emphasis on the protection of sensitive customer information.

Prepare and Maintain Audit Findings:

Provide timely feedback to Manager and department leaders on audit findings based on established claim guidelines. Provide recommendations for new or modified processes and procedures to reduce claims errors. Prepare audit reports for internal and external business partners as needed and serve as the point of contact for claim audit questions. Track and champion open system items and work with Manager to advocate for timely resolution. 

Collaboration with other Vaya Departments: 

This position will work with internal and external business partners to identify system deficiencies affecting claims processing and monitor for resolution. 

Other duties as assigned.

KNOWLEDGE, SKILL & ABILITIES

• Ability to tactfully communicate audit results when providing feedback to co-workers, supervisor and managers
  
• Strong attention to detail and data accuracy
  
• Strong computer skills and the ability to learn additional databases and review multiple applications and/or screens at one time
  
• Must have strong time management skills
  
• Must have efficient and effective verbal and written communications and listening skills.
• Ability to make quick and effective independent decisions
• Ability to problem-solve, and resolve challenges in a timely, professional manner
• Excellent written and oral communication skills
• Can work independently, and with a team, to meet deadlines
• Must be proficient in the following software applications: Microsoft Word, Excel, Outlook, and SharePoint
• Must be proficient or able to quickly learn the organization’s claims adjudication system and NC Tracks or any other multi-payer management information system for NC Department of Health and Human Services
• Knowledge of claims adjudication processes, provider contracting and credentialing and member eligibility and the impact of these three functional areas working collaboratively to support successful claims processing
• Well-developed understanding of the health insurance industry and an in-depth understanding of healthcare data analysis

QUALIFICATIONS & EDUCATION REQUIREMENTS

High School Diploma or GED with at least 5 years of claims auditing experience in a related field –OR—an Associate Degree and 2 years of post-degree experience in claims auditing in a related field. Associate degree in Business Administration, Hospital Billing, or related field preferred.

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. 
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. 
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. 
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: The person in this position must live in NC, SC, GA, TN, VA, MD, or FL.

SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation. 

DEADLINE FOR APPLICATION: Open Until Filled.

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.