Manager, Claims Auditing And Reporting

WHO IS GUIDEHEALTH?

At Guidehealth, our mission is to enhance healthcare affordability for patients and restore the fulfillment of practicing medicine for providers. As a physician-led company, we recognize that streamlining administrative tasks and harnessing the power of predictive analytics and AI enable our partner physician practices prioritizing delivering high-quality healthcare focused on outcomes and value.

Driven by empathy, we empower physicians to anticipate the needs of patients requiring more attention, strengthen connections between patients and physicians with virtually-embedded Healthguides, and leverage AI and analytics to proactively avoid preventable events. This approach results in increased levels of patient and practice engagement, ultimately leading to more significant positive impacts on patients.

Join us as we put healthcare on a better path!!

As the Manager, Auditing & Reporting you will lead your staff to an exceptional performance level by giving quality objectives and opportunities to expand their knowledge of services, products, and troubleshooting techniques which will focus on improving performance and processes in an effort to better support customers and internal department procedures.

WHAT YOU’LL BE DOING

• Managing the Auditing & Reporting Department, which includes the staff responsible for routine monitoring and audits of procedures, including but not limited to billing systems audits, Encounter submission audits, provider-level audits, client audits, refunds, and client reporting.
• Determining department operational strategies by conducting assessments, capacity planning, and cost/benefit analyses; identifying and evaluating state-of-the-art technologies; defining user requirements; establishing technical specifications, and production, productivity, quality, and data entry standards; contributing information and analysis to organizational strategic plans and reviews with standard Auditing & Reporting performance metrics.
• Maintaining and improving Auditing & Reporting processing operations by monitoring system performance; identifying and resolving problems; preparing and completing action plans; managing system and process improvement and quality assurance programs.
• Assessing and assigning workflow, coaching, counseling, and disciplining employees; administering scheduling systems and processes; communicating job expectations; planning, monitoring department measures, conducting staff performance conversations; enforcing policies and procedures.
• Ensuring department audit scores meet the 95% score requirement and consistently meet the expectations of the Service Level Agreements, monthly and quarterly reporting requirements.
• Submitting and appeals of the UM Challenges and Reinsurance process.
• Overseeing the Auditing and submission of encounter data and Reporting required by the health plan.
• Understanding and stay current with client contract criteria and requirements ensuring client services are compliant as well as meet client expectations.
• Formulating professional development and educational plans for auditing staff.
• Coordinating operational activities with other internal functions alongside departments and managers.
• Conducting at minimum monthly meetings with staff and attend operational meetings as requested.
• Conducting at a minimum monthly one on one’s with individual staff and annual personnel reviews on staff performance.
• Attending client facing meetings as requested to discuss department statistics and measures.

WHAT YOU'LL NEED TO HAVE

• 2-4 years of supervisory or management experience in Healthcare insurance platforms.
• Background in Value Based Services.
• 1-3 years’ experience processing HMO Claims.
• CPT and ICD coding knowledge.
• Proficient with Microsoft programs (Word, Excel and Access) at an intermediate to advanced level.
• Must be organized, self-motivated, detail oriented, disciplined and a team player.
• Demonstrates the ability to manage staff and multi-task with minimum supervision and the ability to prioritize appropriately.
• Ability to teach and educate others in a manner that best suites the staff.
• Ability to meet deadlines and prioritize tasks; to effectively interact with operational and clinical personnel; collect, correlate and analyze data.
• Excellent written and oral communication.

WHAT WE WOULD LOVE FOR YOU TO HAVE

• Contract and Provider management, claims processing experience, HMO Managed care and Medicare Advantage preferred.
• Medical Coding & Billing certifications.
• Subject Matter Expert in Value Based Services.
• Proficient with Microsoft programs (Word, Excel and Access) at expert level.

COMPENSATION

Guidehealth’s compensation structure includes more than just base salary. We believe in providing world-class benefits including comprehensive medical, dental, and vision plans, long and short-term disability, life insurance, and a 401k plan with a generous match. Our paid time off program includes paid holidays and flexible time that focuses on meeting the demands of the position and our clients, while providing the balance that our employees need.

The base pay range for this role is between $75,000.00 and $85,000.00 per year, paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.

OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT

Diversity, inclusion, and belonging are at the core of Guidehealth’s values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race, religious creed, color, age, sex, sexual orientation and identity, national origin, citizenship, religion, marital status, familial status, physical, sensory, or medical disability, Family and Medical Leave, military or veteran status, pregnancy, childbirth or other related medical conditions, or any other classification protected by federal, state, and local laws and ordinances. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring, placement, promotion, transfer, demotion, layoff, termination, recruitment advertising, pay, and other forms of compensation, training, and general treatment during employment.

This position is responsible for following all Security policies and procedures in order to protect all PHI under Guidehealth’s custodianship as well as Guidehealth Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.