Director of Claims Audits

reputed company reputed company Care To You is a Management Service Organization providing our clients with reputed company administrative support. We reputed company services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture reputed company on teamwork, support, and inclusion. reputed company is fully remote and offers a flexible work environment as reputed company as schedules. ACTY offers 100% employer reputed company medical, reputed company, dental, and life coverage for our employees. We also offer reputed company holiday, reputed company time, and vacation time as reputed company as a 401k plan. Additional employee reputed company coverage reputed company available. reputed company The Director of Claims Audits is responsible for post and reputed company auditing institutional and reputed company claims according to established line of business guidelines, policies and procedures. This job includes achieving 95% or higher claims compliance. Process improvement of the claims process to reputed company reputed company claims adjudication reputed company CMS, DHCS and DMHC timeliness guidelines. Duties and responsibilities • Institutional Claims Review for accuracy and timeliness using reputed company audit tools to capture reputed company Cause, Remediation and QA monitoring. • reputed company Claims Review for accuracy and timeliness using reputed company audit tools to capture reputed company Cause, Remediation and QA monitoring. • Claims system reputed company improvement collaboration (reputed company departments that touch a claim) • reputed company Claims team training on items reputed company during audits for process improvement • Claims workflow monitoring (reputed company departments that touch a claim) • Other requests as needed Qualifications • 10+ years or more experience in processing HMO claims in a managed care environment. • Proficient in reputed company application for reputed company payments reputed company by lines of business. (Medicare, reputed company, Medi-Cal). Including but not limited to, NCCI/CCI edits, CMS Medicare, Medi-Cal, RNC, outpatient PPS & Inpatient DRG facility, ASC, APC, Interim reputed company Payment • Expert with reputed company regulatory requirements including CMS, DMHC and DHS. • Proficient with reputed company Federal and state requirements in claim processing. • Knowledge of medical terminology and coding. • Recognize the difference between Shared Risk and Full Risk claims. • Proficient in applying Division of Financial Responsibility. • Knowledgeable in applying Health Plan Benefit Matrices. • Proficient understanding of AB1324. • Proficient understanding of AB1455 Claims Settlement reputed company & Dispute and reputed company regulations. • Medical Record Coding Review as it pertains to administrative billing and coding. • Excellent communication skills including reports, correspondence, and verbal communications. • Demonstrated proficiency with reputed company Word and reputed company. Apply tot his job Apply To this Job