Vaya Health Hiring for Supervisor – Claims Quality Assurance at Asheville, NC  Full Time

LOCATION: Remote

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

GENERAL STATEMENT OF JOB:

The Claims Quality Assurance Supervisor supervises and coordinates the daily work activities of Claims Audit Specialists, applying knowledge of claims audit standards and procedures. The position provides oversight of audits to verify organization adjudication rules are in compliance with contractual requirements. The Claims Quality Assurance Supervisor engages in routine interface with leadership from the Claims and Reimbursement, Utilization Management, and Provider Network Operations to determine root cause analysis for audit deficiencies and support the implementation of corrective action. This position will manage data and information, and require a well-developed understanding of the health insurance industry and an in-depth understanding of healthcare claims data. The Claims Quality Assurance Supervisor may participate in cross functional teams; as well as participate and/or facilitate special work teams to accomplish business objectives.

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:

Coordination of Claims Audit Processes

This position coordinates the day to day audit workflows and processes for a team of claim auditors. Position will provide audit support to the team as needed to include conducting the completion of routine and specialized audits. Will work with Claims Quality Assurance Manager and internal business partners to identify system deficiencies and organizational processes that impact claims processing. Performs review of work activities completed by Claims Audit Specialists. Conducts analysis utilizing various information systems and reporting tools. Trouble-shoots problems/concerns and facilitates problem solving among staff and provider billing representatives. Submits reports as requested to department leadership, and completes timely requests from other department leadership as needed.

Administrative Supervision and Functions

Responsible for the direct supervision of a team of claim auditors that consist of the following: Provides technical assistance and technical training to staff, keeps staff abreast of all changes involving systems in use and policies/procedures, responsible for ensuring relevant policies and procedures and work flows are current and revised as needed. Provides support to ensure timely resolution of claim audit concerns. Coordinates the recruitment/selection of new employees and recommend new hires. Provides ongoing feedback to staff regarding job performance. Responsible for performance evaluations, disciplinary action, approving and coordinating leave, coordinating work schedules, signing off and approving timesheets and travel forms. Conducts regularly scheduled staff meetings with all staff reporting to the position.

Claims Audit Documentation Management

Will assist in compiling audit findings to be used in feedback to business partners for timely resolution of financial and operational risks to the organization. Will assure that all staff on the claims audit team have access to current procedures and materials, and are conducting work in accordance with these standards. Will coordinate sharing of information between the claims audit team, claims department and all other departments as required.

Training

This position will assure that system requirements, processes, and standards, are being communicated to staff on the claims audit team, and that training materials, training sessions, and all system requirements and expectations are clearly and consistently communicated. Will coordinate with other departments and available external resources to see that the staff training program reflects current industry standards and practices.

Other duties as assigned.

This position will perform other duties as may be directed by the Claims Quality Assurance Director, Claims Quality Assurance Manager, or other department leadership. This may include responding to external and internal requests for claims audit information and completing reports of an important and sensitive nature.

QUALIFICATIONS & EDUCATION REQUIREMENTS:

A High School Degree is required with five years of experience involving claim auditing, billing or coding, or a similar job field; of which 1 year is supervisory or coordination experience in behavioral health or medical claims auditing/coding, or a similar job field (can be inclusive of the total five years experience required). An Associate’s Degree is preferred with 3 to 5 years experience in claims auditing, billing or coding, or a similar job field; or an equivalent combination of education and experience. Previous supervisory or coordination experience of 1 year or more in behavioral health or medical claims auditing/coding, or a similar job field.

Medical claim auditing experience preferred.

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:

* Considerable knowledge and experience in medical claims auditing and claims processing systems and procedures.

* Understand CPT, HCPCS, ICD-9-CM and ICD-10-CM medical claims coding regulations and guidelines.

* Knowledge of Medicaid, Medicare and other 3rd party payment sources.

* General knowledge of accounting practices and procedures.

* Analytical problem solving, verbal and quantitative skills.

* Ability to exercise judgment and discretion in establishing, applying, and interpreting policies and procedures.

* Excellent communication skills, both verbal and written.

* Ability to drive process improvement.

* Very strong organizational and business process skills with attention to detail.

* Ability to prioritize and work independently on a variety of assignments with minimal supervision.

* Ability to accurately determine deadlines and ask for help if needed.

* Ability to establish and maintain effective working relationships with agency personnel, officials, and the general public.

* Ability to work independently, self-start and take ownership for all aspects of the position and necessary knowledge needed on a going basis.

* Proficiency with Microsoft Office to included Excel, data analysis, and secondary research.

* Must be proficient or able to quickly learn the organization’s claims adjudication system and any multi-payer management information system for NC Department of Health and Human Services.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit