Lead Claims Specialist - Claims Recovery

at  Providence

DESCRIPTION

Manage the claims internal audit functions, which includes audit process for adjudicated claims and encounters. Monitor check run process for accuracy. Develop policies and procedures for periodic claims audits and ensure compliance with affiliated health plans, client groups, and administrative contractual agreements. Designs, plans, directs and implements claims training programs for the organization, to include adaptations to changes in policies, procedures and technologies. Must be familiar with applicable State and Federal claim payment and denial timeliness legislation. Must be familiar with Timeliness Compliance pursuant to State and Federal rules and regulations. Must be well versed regarding the Provider Dispute Resolution tracking mechanism (AB1455). Responsible for ensuring customer (provider-vendor) satisfaction while maintaining the integrity.
Providence caregivers are not simply valued – they’re invaluable. Join our team at Providence Medical Foundation and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.

REQUIRED QUALIFICATION:

• Bachelor’s Degree
• 10 or more years HMO claims processing and/or auditing experience in a managed care environment, preferably PMG/IPA setting within the last 7 years or any combination of education and/or experience which produces an equivalency.

Please refer the Job description for details