Manager Claims Internal Quality Audit

Job Description

The Manager of Internal Quality Audit is responsible for ensuring compliance with company policies and state and federal regulations through effective internal audits. This includes staying updated on regulatory changes that may impact auditing processes. The manager aims to maximize the effectiveness of audits in improving overall quality within the organization. This involves identifying areas for improvement and implementing corrective actions based on audit findings. Additionally, the Manager monitors the auditing process and ensures audits are thorough, objective, and conducted according to established standards and procedures. Responsible for identifying opportunities for departmental optimization, by streamlining processes, improving communication channels, or enhancing training programs based on audit insights. Specifically overseeing audits related to pre and post-pay Claims & PDR Audits. Focus areas include accuracy in claim determination, procedural, dollar, and clerical accuracy. Ensures that departmental and individual performance targets are met or exceeded. The manager leads efforts in root cause analysis, generating and monitoring key performance metrics and reports. Overall, the Manager of Internal Quality Audit plays a pivotal role in ensuring that the department operates with high standards of compliance, efficiency, and quality through effective auditing practices and continuous improvement initiatives.

Responsibilities

Manage, monitor, and require all direct reports to meet and/or exceeded goals. Create measures and goals to ensure compliance with regulatory guidelines and maximize cost effectiveness for the department. Evaluate and assess staff on a monthly (performing 1:1’s) and yearly basis, providing timely performance evaluations and implementing corrective action when necessary.|Monitor and manage claims inventory daily to ensure all acknowledgements are completed within 15 working days and all claims are processed within the regulatory guidelines. Run claims inventory report daily and ensure outstanding claims are handled timely. Develop and implement strategy and planning to reduce claims inventory, improving quality results, and maximizing claims compliance efforts.|Work closely with Provider Relations to review and distribute project requests. Ensure that Health Plan audits are pulled timely and reviewed for accuracy.|Ensure confidential and accurate processing of all incoming employee claims.

Qualifications

Three (3) years experience in Medical Claims Management required. Five (5) Year’s experience in Managed Care required. Have the ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC Regulations.High School Diploma or GEDBachelors degree or equivalent education and experience preferred.