Job FamilyClaimsJob Brief
We are currently seeking a dynamic Senior Claims Quality & Compliance Specialist to join our team at our office in Woburn, MA!
ExemptAbout the Position:
We are currently seeking a dynamic Senior Claims Quality & Compliance Specialist
to join our team at our office in Woburn, MA! The Senior Claims Quality & Compliance Specialist conducts and supports internal audits and plan audits, is involved with fraud and abuse prevention and investigation, and actively researches and facilitates a resolution when complaints are received from our provider community through governing bodies. The incumbent will work closely with both Claims and Quality Control Management to ensure policies and procedures regarding internal Auditing and Fraud & Abuse are adhered to as well as producing daily and monthly quality control reports to show compliance. Through a solid understanding of behavioral health claims and how to both interact and present to clients the Senior Claims Auditor & Compliance Specialist will help Beacon Health Options fulfill its mission.Position Responsibilities:
- Participate in internal audits to ensure all claims are adjudicated in accordance with Plan, State and Federal regulations and adjudication logic. (This includes CMS and direct clients.)
- Serves as the voice of Beacon Claims and Quality Control for external audits
- Conducts claims investigations to insure proper billing practices from contracted and non-contracted providers.
- Participates in Fraud & Abuse committee meetings
- Produces and maintains recurring reports that show Claims quality, both representing the overall Service Center and specific to our plan customers.
- Reviews results timely and come to independent conclusions that can be explained clearly and supported through data
- Keeps management apprised of issues that may arise
- Assist in training new staff
- Other job duties as assigned
- Education: Bachelors Degree required
- Relevant Work Experience: 5 years experience, including but not limited to Claims
- Knowledge, Skills, & Abilities:
- Must understand Behavioral Health Claims
- Must understand standards of documentation usually associated with external audits, not limited to CMS or specific clients
- High proficiency in Microsoft Excel and Microsoft Office applications (Specifically OneNote and SharePoint)
- Excellent analytical skills
- Able to communicate effectively with all levels of staff and customers
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Beacon Health Strategies, LLC., a Beacon Health Options company, is proud to be an Equal Opportunity Employer as well as a Drug Free Work Environment. EOE/M/F/Veterans/Disabled.
AAP Reporting Location:MA - Woburn
ID (Req #):53831
FTE Status:Full Time