Health Plan Operations Manager (Call Center Audit Lead)...

LOCALS PREFERRED SHOULD WORK IN W2 We are seeking a highly skilled and experienced professional to join our team as a Health Plan Operations Audit Expert with a specialization in Call Center and Claims Integrity Auditing for MedicareMedicaid SNP (Special Needs Plan) claims. This role is critical in ensuring compliance with regulatory requirements, maintaining claims accuracy, and optimizing operational efficiency within our organization's health plan offerings. Qualifications: Bachelor's degree in Healthcare Administration, Business Management, Finance, or related field; Master's degree preferred. Extensive experience (5+ years) in health plan operations, claims management, or auditing, with a focus on Medicare and Medicaid SNP claims. In-depth knowledge of Medicare and Medicaid regulations, policies, and procedures governing claims processing and billing. Proven track record of developing and implementing audit protocols, methodologies, and quality improvement initiatives. Relevant certifications (e.g., Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), Certified Internal Auditor (CIA)) preferred. Responsibilities: Claims Integrity Audit Management: Lead and oversee all aspects of claims integrity auditing processes for Medicare and Medicaid SNP claims. Develop and implement audit protocols, methodologies, and procedures to ensure comprehensive coverage and accuracy assessment. Conduct regular audits of claims data, documentation, and processes to identify discrepancies, errors, and areas for improvement. Collaborate with internal stakeholders, including claims processing teams, compliance officers, and data analysts, to address audit findings and implement corrective actions. Regulatory Compliance Assurance: Stay updated on Medicare and Medicaid regulations, guidelines, and requirements related to SNP claims processing and billing. Interpret and apply regulatory standards to audit processes and ensure compliance at all stages of claims handling. Provide guidance and support to operational teams to align processes with regulatory expectations and minimize compliance risks.

Created: 2025-01-13