What are the responsibilities and job description for the Claims Compliance Remediation Claims Analyst - Managed Care - Manhattan NY - Hybrid position at Tandym Group?
A healthcare company in New York City is looking to add a new Claims Compliance Remediation Analyst to their growing team. In this role, the Claims Compliance Remediation Analyst will be responsible for supporting the Director of Claims Support to ensure claims rules, guidelines, documents, policies and procedures, reporting, job aides, training, and other key components are compliant with CMS and NYSDOH regulatory entities and maintained within a central repository.
- This is a Hybrid opportunity requiring the qualified professional to work onsite at least 3 days a week.
Responsibilities :
The Claims Compliance Remediation Analyst will :
Support the Director of Claims Support to ensure claims rules, guidelines, documents, policies and procedures, reporting, job aides, training, and other key components are compliant
Partner with the Office of Corporate Compliance to ensure that the Claims Department fully supports company objectives and requirements
Coordinate efforts with the Office of Corporate Compliance and represents the interest of the Claims Department before, during, and after regulatory audits
Ensure documents, workflows, and processes are up-to-date, reviewed annually, and remain compliant, reducing incorrect claims payment as well as reducing claim adjustment requests
Work with the Office of Corporate Compliance, Claims Department, and regulatory entities to facilitate processing of regulatory requests, and escalating performance issues to Claims Department management
Work in collaboration with the Claims training unit to ensure compliance with regulatory requirements
Support corporate training on claims module creation and roll out.
Consolidate significant events (regulations, statues, case law, and other developments for regular reporting to the Claims Department
Coordinate the support for business areas in creating, updating, and monitoring metrics to assess continued compliance with regulatory requirements
Coordinate timely responses of claims corrective action plans and execution of remediation plans
Perform other duties, as needed Qualifications :
3 years of Health Plan Compliance / Regulatory experience; 1 year of Medical Coding experience
Bachelor's Degree
Demonstrated knowledge in sustained Coding Quality
Strong familiarity with CMS and NYS audit protocol
Experience in managed care, Medicare and federal regulations, quality improvement, and compliance oversight
Experience driving corrective action plans (CAPs) and execution of remediation steps
Intermediate to advanced knowledge of CPT / HCPCS / Revenue Code, procedure coding, ICD10 coding, principles and practices, coding / classification systems appropriate for inpatient, outpatient, HCC, CRG and DRG
Demonstrates overall knowledge of Claims Processing for various insurances, both private and government
Ability to compile high level presentations
Solid understanding of Health Insurance law as it relates to compliance
Great interpersonal skills
Excellent communication skills (written and verbal)
Strong attention to detail
Highly organized
