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- Conducts monthly audits of VNS Health Plans claims utilizing VNS Health Plans guidelines, policies and procedures or any other regulatory requirements.
- Reviews internal and TPA production reports to ensure compliance with all regulatory requirements and VNS Health policies.
- Analyzes audit results to recommend system or procedural changes to increase claim accuracy and/or identify opportunities for workflow enhancements.
- Maintains documentation of changes to claim processing guidelines and where appropriate, ensures policies and procedures are created or updated.
- Communicates and follows up either orally or in writing with a variety of internal and external sources including but not limited to providers, members, attorneys, regulatory agencies and other carriers on any claim related matters.
- Evaluates DRG grouping and pricing information.
- Meets individual and departmental standards with regards to quality and productivity.
- Attends meetings with providers as appropriate to assist in communicating proper billing procedures and to explain company coverage guidelines.
- Identifies and documents claim issues resulting from audits or other internal resources.
- Participates in on site audits of the third party administrator as required.
- Resolves provider disputes and complaints received from Providers, Members and internal departments.
- Participates in special projects and performs other duties as assigned.
Claims Auditor - New York, United States - VNS Health
Description
Overview Audits functions of VNS Health Plans claims.Collaborates with other Health plan departments to ensure claims are processed in accordance with established guideline and/or policies and procedures.
Assists in compliance reviews of internal and Third Party Administrator's ("TPA") claims processing policies and procedures. Provides feedback or suggestions to enhance current processes and/or systems. Works under general supervision.Responsibilities
Education:
Bachelor's Degree or the equivalent combination of education and experience required
Work Experience:
Minimum of 3 years related claims and/or auditing experience requiredExperience working in a TPA or HMO or managed care environment preferredKnowledge of Medicare and Medicaid claims requiredPrior training and knowledge of DRG, ICD9 and CPT4 requiredProficient PC skills, including Microsoft Windows requiredKnowledge of HIPAA guidelines required
Compensation Range From and To:
$60, $72,000.00 Annual
About Us
CAREERS AT VNS Health
The future of care begins with you. Together, we will revolutionize health care in the home and community. When you join VNS Health, you become a part of something bigger. For generations, we've been a recognized leader and innovator in patient-centered and community-focused health care. At VNS Health, you'll have the opportunity to meaningfully impact lives. Including yours. Discover your next role at VNS Health.
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