Remote Managed Care Claims Compliance Coordinator

Minimum 3-5 years of experience in the healthcare or managed care industry, including claims/reimbursement experience, professional analytics-related experience and experience working on/managing major projects. Minimum 3 years auditing experience in the healthcare industry. CPT and ICD coding knowledge. Knowledge of Medicare requirements and APC Pricing knowledge. Advanced to expert proficiency in Microsoft Office products (Word, Excel, Access). Ability to function successfully as an Internal Claims Auditor. Ability to problem solve, exercise initiative and make medium to high level decisions. Thorough understanding of current federal, state and local healthcare compliance requirements. Ability to meet deadlines and prioritize tasks; collect, correlate and analyze data. Ability to work independently with minimal supervision and as part of a team. Organized, self-motivated, detail-oriented, disciplined, professional, and a team player. Effective written and oral communication. Bachelor’s degree in healthcare informatics, business administration, or related field, or equivalent in experience and education (preferred). Certified Professional Coder (strongly recommended). Prior claims processing experience within Eldorado HealthPac Claims Adjudication System (a plus). Claim coding experience, coding edits experience and APC Pricing knowledge.

Conduct routine monitoring and audits of procedures, including billing systems, encounter submissions, and client audits. Understand and stay current with client contract criteria and requirements. Generate and submit all required Commercial claims reporting. Prepare for annual Health Plan audits. Confirm pricing accuracy in fee tables. Monitor internal and external processes for fraud, abuse, or waste. Participate in auditing and submitting appeals and UM Challenges for Reinsurance process. Run access queries and impact reports. Assist coworkers and Internal Auditors with compliance and auditing responsibilities. Consistently exercise independent judgment and discretion.