Claims Compliance Remediation Analyst

***MUST HAVE MANAGED CARE EXPERIENCE WITHIN NYS HEALTHCARE PROVIDER NETWORKS***

The Claims Compliance Remediation Analyst will support the Director of Claims Support to ensure claims rules, guidelines, documents, policies and procedures, reporting, job aides, training, and other key components are compliant with CMS and NYSDOH regulatory entities and maintained within a central repository. This incumbent will partner with the Office of Corporate Compliance to ensure that the Claims Department fully supports company objectives and requirements. The incumbent will also coordinate efforts with the Office of Corporate Compliance and represent the interest of the Claims Department before, during, and after regulatory audits (internal and external). This role is critical to the Claims Department by ensuring documents, workflows, and processes are up-to-date and compliant, reducing incorrect claims payments as well as reducing claim adjustment requests, thereby reducing both medical and administrative expenses.

Job Description

• Support the Director of Claims Support to ensure claims rules, guidelines, documents, policies and procedures, reporting, job aides, training, and other key components are compliant with CMS and NYSDOH regulatory entities and maintain within a central repository.
• Partner with the Office of Corporate Compliance to ensure that the Claims Department fully supports company objectives and requirements.
• Coordinate efforts with the Office of Corporate Compliance and represents the interest of the Claims Department before, during, and after regulatory audits (internal and external).
• Ensure documents, workflows, and processes are up-to-date, reviewed annually, and remain compliant, reducing incorrect claims payment as well as reducing claim adjustment requests.
• Work with the Office of Corporate Compliance, Claims Department, and regulatory entities to facilitate processing of regulatory requests, and escalating performance issues to Claims Department management.
• Work in collaboration with the Claims training unit to ensure compliance with regulatory requirements.
• Support corporate training on claims module creation and roll out.
• Consolidate significant events (regulations, statues, case law, and other development(s)) for regular reporting to the Claims Department via a “Claims Compliance Newsletter”.
• Coordinate the support for business areas in creating, updating, and monitoring metrics to assess continued compliance with regulatory requirements.
• Coordinate timely responses of claims corrective action plans and execution of remediation plans.
• Oversee other projects as needed.

Minimum Qualifications

• Bachelor’s degree required
• 3-5 years’ health plan compliance/regulatory experience
• 1+ year of medical coding experience, with demonstrated knowledge in sustained coding quality
• Strong familiarity with CMS and NYS audit protocol
• Experience in managed care, Medicare and federal regulations, quality improvement, and compliance oversight
• Experience driving corrective action plans (CAPs) and execution of remediation steps
• Intermediate to advanced knowledge of CPT/HCPCS/Revenue Code, procedure coding, ICD10 coding, principles and practices, coding/classification systems appropriate for inpatient, outpatient, HCC, CRG and DRG
• Ability to research authoritative citations related to coding, compliance, and additional reporting needs.
• Demonstrates overall knowledge of claims processing for various insurances, both private and government
• Ability to compile high level presentations
• Solid understanding of health insurance law as it relates to compliance