Claims Auditor

What You’ll Be Responsible For

• Conduct reviews of claims processes against policy provisions and governing regulations to ensure compliance.
• Conduct claims audits including standard audits and focused audits, to ensure accuracy and integrity of the claims processing system, working with PACE System Administrator on necessary system updates.
• Ensure that claims are processed in compliance with agency and department policies and procedures, contractual agreements, and governing federal and state regulations.
• Respond accurately, timely and professionally to all external and internal communications regarding claims audits, ensuring clarity and accuracy in all interactions.
• Review and work weekly/monthly claims data reports from the claims processing system and maintain productivity goals set forth.
• Review and approve weekly Precheck Registers for all PACE Organizations.
• Ensure all claims appeals are worked timely across all PACE Organizations relevant to governing regulations and contract obligations.
• Assist claims staff and PACE Organization staff in reviewing situations that may warrant focused claims audits.
• Reviews claims for proper billing and processing, including timely submission, compliant coding, required authorizations, and accurate pricing and payment.
• Aid staff on questions and issues related to pricing of claims.
• Maintain accurate and detailed records of all claims audits, including documentation of actions taken, communications with internal staff, and corrective actions implemented.
• Prepare and submit regular reports on claims processing accuracy and trends to the Claims Manager, Director of Health Plan Operations, VP PACE Business Operations, and other relevant stakeholders.
• Maintain knowledge of PACE, CMS, and state Medicaid policies and claims guidelines.
• Develop and implement claims auditing policies and procedures, contributing to the overall effectiveness and accuracy of the claims processing team.
• Communicate to and prepare reports for the Claims Manager, Director of Health Plan Operations, VP PACE Business Operations, and PACE Executive Directors.
• Support various projects from across the PACE Organizations and community-based program enterprise.
• Assist with other duties and projects as assigned.

Why You’ll Love It Here

• Opportunity to shape strategy and drive organization-wide impact
• Collaborative executive leadership team that values partnership and accountability
• High-visibility role influencing performance, processes, and outcomes
• Cross-functional collaboration across operations, finance, and clinical teams
• Culture that empowers leaders to innovate, improve, and build strong teams