Responsible for claims data analysis, development of report specs to support audit oversight and preparation for health plan and regulatory audits based on regulatory requirements, internal policies, and industry standards. Requires knowledge of current and emerging regulatory requirements, and use of industry-standardized tools. Primary Responsibilities:Maintains oversight to health plan and regulatory audit requests by developing and preparing required data reports. Manages reporting changes and performs quality audits for accuracy of reports in alignment with requested report criteriaMaintains data library and performs annual review of reports to maintain reporting integrityPrepares Monthly Timeliness and health plan/regulatory audit reportsPerforms complex pre-audits in preparation for scheduled audits and documents findings on appropriate formsResearches claim processing problems and errors to determine their origin and appropriate resolution. Prepares reports for management summarizing observations and recommendationsAssists management with their evaluation of controls and acts as a consultant to suggest ways to mitigate risk areasCompletes audit and internal corrective action plans (CAP) based on audit findings and monitors to ensure future complianceParticipates in communication with Business Operations management regarding results of claims audit process in order to improve processes and payment integrityProvides qualified data for incorporation into training programs, policies and procedures, and standard operating proceduresPerforms special project audits and reviews as requested by other departments/regionsRegular and consistent attendance
Required Qualifications:3+ years of experience with Medical Claims experienceExperience working with Medicare / Medicaid / HMOKnowledge of healthcare regulations and guidelines including CMS and MHC as pertains to AB1455Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms, and CPT Coding Preferred Qualifications:Associate's Degree (AA) or equivalent experienceIntermediate skill levels in Microsoft Word, Excel and OutlookAbility to write routine reports and correspondenceAbility to speak effectively before groups of customers or employees of the organizationAbility to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebraAbility to apply common sense understanding to carry out instructions furnished in written, oral, and diagram formAbility to deal with problems involving several concrete variables in standardized situationsDetail oriented What's the first thing that happens when one of the most successful physician groups in Orange County comes together with a global leader in health care? Opportunity. With Monarch HealthCare joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. With a vibrant network of hospitals and urgent care centers, we're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do your life's best work.(sm) Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. Job Keywords: Claims examiner, Medicare, HMO, disputes, resolution, AB1455, provider, appeals, CCI, Health plans, Correct Coding Initiative, HCFA-1500, UB-92, CPT Coding, Irvine, CA, California
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.