Key Accountability Metrics
- Plan, coordinate, develop and implement approved projects in order to enhance the overall efficiency of operational procedures, methods, controls and performance.
- Responsible for compiling and reporting any accuracy errors found while auditing up to various levels of leadership.
- Provide leadership team with status of projects; issue, communicate and recommend policy decisions to achieve project objectives.
- Perform special audits of provider payments for payers as requested by regulators, contracting, and internal management.
- Represent department as requested on work groups and special assignments, including related testing.
- Requires knowledge of claims processing for HCFA.
- Function as subject matter expert specific to the audit function and claims.
- Identify documentation or delivery defects and gaps presenting recommendations as required.
- Maintain SOP’s for all auditing procedures/policies and review on a regular basis.
- Work closely with management and supervisory staff and other subject matter experts to develop training and/or documentation needs.
- Develop and implement quality control audit plans.
- Identify testing parameters for auditing purposes and validity.
- Assign team members to quality audits and oversee their work, if applicable.
- Train employees on quality standards and procedures.
- Ensure that processes comply with industry standards.
- Document defects and recommendations for improvement.
- Prepare and present quality audit reports to senior management.
- Keep abreast of industry standards and regulations.
- Utilize up-to-date technical skills to navigate through electronic leadership tools and platforms; with the ability to test new tools as required.
- Perform analytical claims/call issue review to develop training opportunities
- Develop SOP/Desk-level procedures to ensure quality outcomes.
- Be responsible for overseeing policy and procedure review and completing full/complex desk or pre-delegation, annual or follow-up onsite audits/assessments of delegated entities, including vendors, in support of the regulatory, CMS and NCQA requirements.
- Research, investigate and oversee delegated entity’s compliance with reporting requirements by tracking the receipt and evaluating the completeness of reports.
- Provide highly complex analyses and define efficiencies in relation to compliance programs and internal controls.
- Collaborate on regulatory audits, and findings responses.
- Assist in the development of delegation policies and procedures and associated staff training.
- Assist in the development of audit tools, correspondence templates, etc. to external entities.
- Conduct thorough assessments and audits of processes, procedures, and documentation to ensure alignment with established quality standards, regulatory requirements, and organizational objectives.
- Initiate and maintain cooperative relationships with co-workers, managers and supervisors, claimants, and members of the public.
- Performs increasingly difficult office audits of claims and other business records and documents to determine or verify compliance with laws and regulations.
- Maintains, records, and submits written reports concerning cases and activities.
- Perform other duties as assigned