Compliance Claims Auditor

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Job Overview

The Compliance Claims Auditorplays an integral role in MetroPlusHealth's Compliance Program ensuring overall compliance with our claims processing obligations through audit and ongoing monitoring activities.The individual in this role will provide compliance oversight of processed claims analyzingtrends and errors and driving root cause and impact analysis of identified findings. The Compliance Claims Auditor will also work with operational areas to implement corrective actions when required.

• Assist in the development of compliance claims auditing and monitoring activities: including objective, scope, methodology and audit schedule, document, and universe data requests.
• Applying claims expertise to review and investigate claim transactions and identify inappropriate or noncompliant processing of claims within the scope of the audit/monitoring activity.
• Develop audit report of findings outlining deficiencies and providing recommendations for corrections or process improvements.
• Assist in the development of desk aids/workflows for specific as needed.
• Assist Manager of Claims Business Process Monitoring in facilitating workgroups with operational areas to monitor timely implementation of corrective actions, controls, or mitigation strategies.
• Conduct in-depth research of provider payment agreements, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends then provide recommendations for mitigation/process improvement/resolution.
• Other duties as assigned or requested.

• Bachelor's degree in a health-related field.
• Minimum of 4 years of experience performing claims audits in a managed care setting
• Extensive knowledge of health care provider audit methods and data analysis techniques to improve operational processes where compliance gaps have been identified.
• Strong knowledge of CMS Medicare and NYS regulations and claims processing requirements for multiple lines of business (Medicaid, Medicare, Child Health Plus, Commercial, and large group insurance programs)
• Thorough knowledge of medical terminology, CPT, ICD-9, and Revenue Codes.
• Some project management skills and ensuring documents are organized and archived well are preferred.
• Experience with developing reporting and metrics.

Professional Competencies

• Excellent oral, written, and presentation skills.
• Strong problem-solving skills.
• Works well independently and in a workgroup partnering with other business areas to resolve deficiencies.
• Sound working knowledge of Windows-based software packages, including Word, Excel, PowerPoint, SharePoint, and online/Internet-based research tools.

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