Claims Delegation Oversight Auditor
Location: Orange, California US
Job Number: 2033
Position Title: Claims Delegation Oversight Auditor
The Claims Delegation Oversight Auditor (CDOA) reports directly to the Claims Delegation Oversight Manager (CDOM). The CDOA assists the CDOM in obtaining the necessary information from the IPAs, coordinating audits, performing data validations and assists with compliance reporting and submissions to AHCs internal Compliance Department. The CDOA also assists the CDOM with audits conducted for Alignment Health Plan’s delegated entities as it relates to claims processing.
(May include but are not limited to)
- Assists with the oversight and auditing for downstream entities delegated for claims processing, which may include:
- Site visit
- Written review
- Exchange of documents or through pre-meetings
- Assist with conducting pre-delegation evaluations for potential delegated entities (IPAs) which includes, but not limited to:
- Obtaining IPA reports, data and information
- Scheduling/coordinating meetings with the IPAs
- Tracking and reporting of pre-delegation results to the CDOM
- Assist the CDOM with auditing of the delegated entities to ensure performance maintenance through the following:
- Review contractually established performance metrics monthly
- Use a range of data sources to evaluate adherence to compliance
- Immediately and clearly share new state guidance with delegates
- Set rules for sub-delegation
- Assist CDOM with performance correction of delegated entities through the following:
- Communicate overall needs to delegates—define big picture success for them
- Have a corrective action approach where an oversight for those delegates who fail to meet expectations which includes:
- Corrective action plans
- Be prepared to terminate provider for failure to meet performance levels
- Assist with annual claims audits/evaluations via desk and onsite audits
- Assists with obtains required claims compliance reporting, which includes but not limited to: monthly timeliness reports, Part C reporting, Provider Dispute Resolution and ODAG.
- Assist with streamlining oversight activities to ensure as much automation and efficiencies as possible.
- Works in conjunction with internal Compliance and Delegation Oversight and Monitoring Manager.
- Other duties as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Education and/or Experience:
- Requires a high school diploma (bachelor’s degree in a related area is preferred)
- A minimum 1 year of experience in the field. Familiar with a variety of the field's concepts, practices, and procedures is preferred.
- Relies on experience and judgment to plan and accomplish goals. Manages staff and typically reports to top management.
- At least 2 years of management experience
- Prior Medicare Managed Care claims processing experience related to delegation oversight and auditing.
- Demonstrable detailed knowledge/experience with CMS claims compliance reporting – Part C, ODAG, Monthly Timeliness, etc.
- Certificates, Licenses, Registrations: None required.
- Other Qualifications:
Skills and Abilities
- Possesses and demonstrates a strong willingness/openness to change and actively make improvements towards efficiencies and automation.
- Possesses and demonstrates a strong working knowledge in claims processing for Medicare Advantage members based on CMS regulations and guidelines.
- Possess strong written and verbal skills.
- Ability to be proactive and solution oriented.
- Possesses strong follow up and follow up abilities.
- Possesses abilities to scope and identify potential issues and escalate accordingly and proactively.
- Possesses and maintains strong working knowledge of regulatory and compliance claims reporting.
- Possesses prior experience with system testing and leading User Acceptance Testing sessions.
- Possesses strong ability to evaluate data for accuracy and integrity in order to report on any issues and trends.
- Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.
- Mathematical Skills: Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.
- Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
- Computer Skills: Knowledge of computer programs and applications required. Highly experienced skillset with using MS Office products such as MS Excel, Access, Word, etc.
- Other Skills and Abilities:
- Knowledge of medical terminology
- Detail oriented.
- Follow instructions accurately.
- Must know computerized claims processing systems.
- Data entry and 10-key skills by touch and sight.
- Knowledge of MS Office – Outlook, Word, and Excel.
- Knowledge of claims coding, CPT, RVS, ICD-10, HCPCS or other coding.
- Knowledge of State and Federal Regulatory claims requirements.
- Comprehensive knowledge of medical terminology.
- Excellent verbal and written skills.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
- The employee is frequently required to reach with hands and arms.
- The employee is occasionally required to stand; walk; climb or balance and stoop, kneel, crouch, or crawl.
- The employee must occasionally lift and/or move up to 25 pounds.
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- The noise level in the work environment is usually moderate.
Location City: Orange
Location State: California
Community / Marketing Title: Claims Delegation Oversight Auditor
Who is Alignment Healthcare?
- Socially responsible
- Technologically enabled
- Concierge care
- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.