What are the responsibilities and job description for the Auditor, Claims position at Independent Living Systems?
ABOUT US
Join us in making a career in Independent Living Systems, an industry leader in managing home and community-based programs for over 20 years. Independent Living Systems, LLC and its subsidiaries offer a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid, and Dual-Eligible Market. ILS provides tailored integrated solutions aimed at improving health outcomes while rebalancing costs, addressing social determinants of health and connecting members with community-based resources.
Position Summary
The Claims Auditor is responsible to develop, monitor and implement quality assurance indicators to ensure excellent service delivery. Recommend modifications, quality enhancements to streamline processes and improve service to providers. Develop and facilitate training modules for the staff.
Essential Functions
- Monitor quality assurance of Provider Service, Claims and Correspondence Advocates by performing call monitoring and auditing of claims and written inquiries.
- Review a percentage of processed claims for accuracy on a daily basis.
- Provide feedback to examiners consistently and in a timely manner.
- Identify trends / issues / deficiencies related to service quality provided by Provider Services staff; make recommendations for modifications and / or improvements to streamline processes and improve service to providers.
- Keep management informed of quality issues / trends adversely impacting service levels; suggest and / or implement corrective action.
- Compile quality data; prepare individual and departmental statistical reports for management.
- Review quality statistics and trends; make recommendations for modifications and / or improvements; coordinate efforts with management to implement necessary steps for improvement.
- Ensure departmental compliance with Company policies and procedures, NYS, federal and HIPAA guidelines and regulations.
- Develop and design reports to quantify quality assurance measurements for executive level review.
- Coordinate, design and prioritize quality assurance initiatives to enhance CSA development and overall service excellence.
- Interact with management to assess training needs; translate client business objectives into measurable course objectives.
- Develop, coordinate and conduct training programs for new employees.
- Coordinate, design, and prioritize quality assurance initiatives for current staff to enhance performance and identify Provider Services “best practices”.
- Design platform training programs including outline, text, handouts, tests, visual and audio support tools.
- Develop / implement testing tools to ensure retention.
- Coordinate efforts with Manager to collect appropriate data used to evaluate the training process, probationary reviews, and evaluations, overall work performance of Provider Services staff.
- Generate reports to document testing, training, assessment and qualification / certification documentation.
- Coordinate, monitor, and update all client policy and procedures, mailing literature and regulatory requirements.
- Prioritize all work delegated by the Manager.
Education and Experience
- High School diploma/GED required; college graduate preferred.
- Minimum one (1) year experience processing HCFA / UB92 claims required.
- Proven record of excellence in claims processing accuracy.
- Thorough knowledge of automated claims systems and procedures.
- Training experience, platform / presentation skills, project management and program design preferred; ability to effectively respond to queries (verbal and written) from clients, regulatory agents, management, and staff required; “Certified Trainer” or related certification preferred.
Required Skills
- Financial Management.
- Communications Proficiency.
- Presentation Skills.
- Strong knowledge of Customer Service skills and techniques required.
- Excellent written, verbal, and grammatical communication skills required.
- Ability to read, interpret, and analyze technical / business procedures and / or governmental regulations required.
- Ability to write reports, business correspondence and procedural manuals required.
- Knowledge of automated systems (technical adeptness) required.
- Demonstrated proficiency in Microsoft programs (i.e., Excel, Word, and PowerPoint) required; knowledge of Microsoft Access preferred.
EEO STATEMENT
In compliance with the Drug-Free Workplace Act of 1988, Independent Living Systems has a longstanding commitment to provide a safe, quality-oriented, and productive work environment. Alcohol and drug abuse pose a threat to the health and safety of ILS employees and to the security of the company's equipment and facilities. For these reasons, ILS is committed to the elimination of drug and alcohol use and abuse in the workplace. Independent Living Systems, LLC, and its subsidiaries, including FCC, provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, disability, ancestry, or any other characteristic protected by state, federal, or local law. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
