Managed Care Services, Senior Auditor

POSITION SUMMARY/RESPONSIBILITIES

Oversee the auditing of payments made by contracted third-party payers to identify underpayments, trends in underpayment, and opportunities for appeals. This role demands comprehensive knowledge of facility and professional claims, a thorough understanding of claims billing requirements, an in-depth understanding of payer claims processing criteria, as well as the application of payer contract terms to commercial, Medicare Advantage, and Managed Medicaid claims. Offer project support to management and deliver regular updates on projects across various departments to address issues and trended items. Assist in coordinating and enhancing continued oversight of underpayment, overpayment, and other payment trends, as well as resolving identified issues. Collaborate with management and other operational areas to develop solutions for payer-related claims payment issues.

EDUCATION/EXPERIENCE

A high school diploma or equivalency is mandatory. A minimum of five years' experience in insurance, medical, or Managed Care environment, including two years of claim processing experience, is required. Prior auditing experience is highly preferred. Demonstrated expertise in problem resolution, presentation, and communication skills, as well as data management, is preferred. Must have knowledge of Texas Medicaid system (traditional and Managed Care) and the federal Medicare program (traditional and Managed Care), as well as commercial health insurance programs. Knowledge of Lean principles and experience implementing Lean practices is preferred. Must possess strong interpersonal, presentation and communication skills.

LICENSURE/CREDENTIALING

Managed Care or Revenue Cycle certification by Healthcare Financial Management Association is preferred.