Compliance and Claims Auditor
Newtown PA 18940
Job DescriptionThis position is responsible for conducting compliance audits, risk assessments, investigations, education and training assignments relating to billing, coding, reimbursement and documentations. At least sixty percent of this position’s time involves working in the field with vendors, subcontractors and providers. This position is also responsible for conducting claims and compliance audits for the purpose of detecting and/or recovering inappropriate benefit payments due to billing inaccuracies and/or abusive and fraudulent practices, as well as complying with state and federal regulatory compliance and fraud reporting requirements.
- Conduct reviews of behavioral health consumers’ medical record to assess whether covered behavioral health services delivered to the consumer and billed to Medicaid are accurate and appropriate. Prepare detailed audit findings reports. Track and trend compliance statistics and use to implement strategies to improve provider compliance. Implement corrective action as necessary to ensure the highest levels of provider compliance. Conduct re-audits of providers’ medical records to verify corrective actions were fully implemented and effective.
- Collaborate and work in coordination with other Magellan subject matter experts in Special Investigations Unit (SIU), cost containment, legal, claims, network, compliance and external county and federal and state regulatory authorities such as the Bureau of Program Integrity, Department of Public Welfare, Office of the Attorney General and others to identify, investigate and report overpayment, duplicative payment, false claims, abuse, and fraud situations and, as appropriate, assist in the process of recovery of overpayments.
- Review and monitor provider compliance with Medicaid Licensing and billing requirements in all levels of Medical Assistance funded care. Conduct provider and member interviews as a part of the overall review process.
- Ensure providers have a compliance plan and policies and procedures that detail provider expectations. Review, monitor and report on providers’ effective implementation of the plan.
- Further develop comprehensive audit and monitoring tools, provider compliance plan expectations, provider training materials and reporting templates etc. Provide technical assistance as needed.
- Present findings reports at designated meetings (i.e. internal, customer, provider, etc.)
- Ensure compliance regarding HIPAA regulations and forward mandatory reports to designated recipients. Other compliance related duties as instructed.
General Job Information
TitleCompliance and Claims Auditor
Job FamilyLegal Group
CountryUnited States of America
FLSA StatusUnited States of America (Exempt)
Recruiting Start Date1/6/2020
Date Requisition Created12/30/2020
EducationBachelors (Required), Masters
License and Certifications - Required
License and Certifications - Preferred
Other Job Requirements
- Experience working for a Managed Care Company or other health related organization.
- Knowledge of group health or managed care claims payment processes.
- Health Care audit-related experience
- Knowledge of Medicaid licensing and billing requirements, DSM-IV.
- Ability to collaborate with many functional areas of a national organization.
- Large and, at times, complex database management skills coupled with strong working knowledge of Excel.
- Knowledge of HIPAA.
- Healthcare experience.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
Top 5 reasons to work at Magellan
Meaningful Work With People Who Care
At Magellan Health you can do meaningful work and feel confident that you matter in an organization that makes a real difference in the world - one that cares deeply and uses its employees’ collective insight as a competitive advantage.Read More
We are Compassionately Curious
Magellan Health is a place where we listen with real empathy. It’s one of our biggest strengths. It helps us to support each other and develop innovative solutions for the fastest growing, most complex areas of healthcare.Read More
We are Better Together
We rely on our innate ability to work as a high-functioning collaborative team to facilitate compassionate care to all of our members. With such interdependency comes trust, challenge and innovation.Read More
We believe work and life should flow together in unison. We offer resources that match your professional development, a culture that welcomes your ideas, and unparalleled flexibility to fit work around your life.Read More
Be your best at Magellan Health. We’re a collective of remarkably motivated and driven professionals. As a team, we’re proud of the high standards we set for each other and we’re continually inspired to do our best work.Read More
When you sayLife @ Magellan
To be the best you have to work with the bestWe hear you