Position Summary

The Lead, Quality and Audit Specialist, in concert with the Configuration Manager, will develop, implement, review, analyze, and improve audit quality standards across claims and configuration programs and procedures that are designed to drive accuracy and quality results that support Health Options vision, mission, and strategic direction. The person in this role is the subject matter expert and lead auditor for all Claim Operation audit activities and may collaboratively coach and educate other auditors. The lead specialist will also deliver regular reporting that identifies audit quality and accuracy results, along with recommendations for needed education or coaching of individuals or associated areas of opportunity. Auditing activities will include benefit and provider configuration, system-adjudicated and processor-adjudicated claims, including the application of associated benefits and network contracts. In collaboration with external business partners and other Health Options departments, collaborates to drive improved performance through effective audit activities, and monitors partner audit activities and reporting for completeness; includes partner audit results in reporting. Supports other teams and departments in claims related reviews and investigations.

Core Responsibilities/Duties

• Monitors and participates in all audit quality program activities.
• Acts as lead subject matter expert for audit-related inquiries, education, process improvement, and maintains resources and connections needed to continually develop and improve audit program processes and deliverables.
• Support the review of High-Dollar and Complex Institutional Claims
• Act as Subject Matter Expert in responding to internal and external claims processing inquiries
• Prepares analysis reports, and communicates detailed savings report results to Health Options Leadership
• Identify claims for referral to Fraud Waste and Abuse (FWA) vendor, and support casework of SIU for complex referred institutional billing cases
• Compile, report, and present claim audit program results, both from internal auditing and partner vendor auditing.
• Collaborate with and be the lead representative with partner vendors to ensure compliance with Health Options audit program.
• Annual Review and Tracking of Claims Operations and Configuration of Internal and External Policy and Procedures
• Identify individual quality and accuracy areas of concern and collaborate with team managers to deliver needed education or guidance for improved performance.
• Review results of audit finding appeals and determine needed education or process improvement within audit team and program for overturned issued errors.
• Assists the Configuration, Claim Operation Managers and Department Director with all quality audit initiatives.
• Leads, monitors, and drives audit program for system-adjudicated claims, and works collaboratively with configuration team or other stakeholders to improve accuracy and ensure payment integrity for auto-adjudicated claims.

KEY COMPETENCIES

People within Community Health Options are expected to work with integrity, humility, strategic vision, curiosity, and discipline. They must be self-motivated, highly effective, and compassionate communicators, effectively working with people, work processes, and actively engaging in continuous process improvement.

Health Option diversity initiatives are applicable—but not limited—to our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of diversity equity, which encourages and enforces:

• Respectful communication and cooperation between all employees.

• Teamwork and employee participation, permitting the representation of all groups and employee perspectives.

• Work/life balance through flexible work schedules to accommodate employees’ varying needs.

• Employer and employee contributions to the communities we serve to promote a greater understanding and respect for the diversity.

Required Qualifications:

Attention to detail, excellent organization, communication and human relations skills are critical. Highly accountable for work that includes handling of and access to highly sensitive confidential and protected health information (PHI). May make routine decisions in resolving problems/issues, with more complex problems/issues being discussed with input from various departmental leaders and Executive staff. Must have the ability to develop and maintain relationships with all levels of Community Health Options people. In addition:

• Bachelor’s degree or equivalent work experience (minimum of two years of experience working with database, preferably in a managed care setting) or equivalent combination of education and experience.
• Minimum one-year hands-on claims quality audit processing experience
• CPT®, HCPCS, and ICD-10 fluency required; specific studies and certification in coding required.
• Excellent written and verbal communication skills
• Proven organizational skills and attention to detail.
• Demonstrated analytical experience.
• Proficiency with Microsoft Office apps, including expertise with Excel.
• Ability to provide team-oriented guidance and instruction that facilitates an environment of trust with a focus on delivering excellence.
• Performs all other duties as assigned.