LOCATION: Remote

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

GENERAL STATEMENT OF JOB:

This position is responsible for performing weekly quality monitoring on work processes performed in the Claims and Reimbursement department as well as reconciling payment for Medicaid and state-funded encounter data that is sent to the NC Tracks or any alternate multi-payer management information system for NC DHHS. The position provides feedback on findings to department management for process improvement.

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 Internal Quality Audits

This position will audit a random sample of work performed in the department on a weekly basis for internal work processes. Conduct audits to reconcile payment for Medicaid and state-funded Encounter Data that was sent to the NC. Conduct audits to examine the root cause for claim denials received as a result of resubmissions to the NC Tracks multi-payer management information system. Accurately document quality reviews in a detailed and timely fashion according to the parameters and the guidelines defined in the department Standard Operating Procedures (SOPs) and workflows.

Prepare and Maintain Audit Findings

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

Collaboration with other Vaya Departments

This position will work with internal business partners to identify system deficiencies affecting quality audit processes and monitor for resolution.

Other duties as assigned

QUALIFICATIONS & EDUCATION REQUIREMENTS:

High School Diploma or GED with at least 5 years of combined experience in health care claim processing specifically Medicaid, Medicare and other 3rd party payment sources.

-or-

Associates Degree in a related field is preferred with a combination of 2 years of post-degree experience in health care claim processing specifically Medicaid, Medicare and other 3rd party payment sources.

PHYSICAL REQUIREMENTS:

This position must have the ability to establish appropriate and respectful relationships/partnerships with organizational personnel. Ability to work with a multidisciplinary team approach. Ability to assume a helping role and to intervene appropriately to meet the needs of providers, consumers or families served. Works within the established ethical guidelines developed for the profession.

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

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit http://www.vayahealth.com/careers-overview/ Ind.001