Claims and Configuration Auditor, FT Days

PIH Health is seeking a dedicated and detail-oriented individual to join our team as a Claims and Configuration Auditor (CCA). This full-time, mid-career position plays a crucial role in maintaining positive relationships with internal and external customers, health plans, providers, and members. The CCA is responsible for conducting claims audits, providing feedback and education to claims staff, and developing root cause analysis reports to identify trends and prevent non-compliance. The successful candidate will work closely with the Managed Care Management Team to align QA programs with claims operations and adhere to internal SOPs and industry guidelines in accordance with state and federal regulatory agencies. The role involves complex problem-solving related to claims audits, member denials, provider disputes, and potential deficiencies that could jeopardize the Claims Department. Additionally, the CCA assists the Claims Configuration Manager with the configuration of provider contracts, fee schedules, and DOFRs matrices. PIH Health is a nonprofit, regional healthcare network recognized for excellence in patient care and experience. We offer a supportive work environment that fosters professional growth and a commitment to serving the community. The ideal candidate will be proactive, able to work independently with minimal supervision, and possess excellent organizational skills to meet deadlines and complete projects in a timely manner. Confidentiality, honesty, and exceptional customer service skills are paramount in this role. For more information about PIH Health, visit PIHHealth.org or follow us on social media platforms. This is a regular/at-will position based at PHP, and the successful candidate will be instrumental in upholding the company's goals and vision.

Required Skills

• Computer system skills/knowledge (MS Excel and Word) – EXCELLENT
• Written and verbal communication skills GOOD
• Managed Care Knowledge and confidence exposure expected – GOOD
• Knowledge of claims processing, CPT/RBRVS/ICD codes EXCELLENT
• Level of comprehension as it relates to regulatory compliance and guidelines associated with CMS, DMHC, DOI, DHS, etc. EXCELLENT
• Ability to analyze data and understand trends
• Identifies compliance gaps in processes and systems by providing a risk-based solution for prevention HIGH
• Prepares, issues, and tracks deficiencies noted during claims pre/post audit and inspection HIGH
• Extensive knowledge of root cause analysis/trends HIGH
• Organizational skills EXCELLENT
• Knowledge and understanding of contract terms and system configuration
• Configuration of contracts and Division of Financial Responsibilities matrices EXCELLENT
• Ability to work independently with minimum supervision HIGH
• Meet deadlines and completion on assigned projects in a timely manner EXCELLENT
• Ability to take initiative in analyzing problems, developing a solution with a win-win approach EXCELLENT
• Confidentiality and Honesty with compliance HIGH
• Great customer service skills with internal and external customers EXCELLENT
• Communicate with Claims Director and Configuration Manager HIGH

Required Experience

• 5 to 10 years claims processing experience
• Claims auditing and understanding claims processing in a claims department
• Experience in configuration of contracts and Division of Financial Responsibilities matrices
• Experience with implementation of Corrective Action Plan (CAP)
• Knowledge of regulatory requirements (CMS and DHS)
• High School Diploma or equivalent
• Bachelor’s Degree preferred