Claims Oversight & Compliance Manager

Arizona Priority Care (AZPC) is an Integrated Provider Network focused on providing whole-person care to Senior and Medicaid populations, through advanced value-based models. Our provider network is comprised of more than 6,000 health care providers, including primary and specialty care physicians, hospitals and ancillary providers. We have operated in the Arizona market for more than 14 years, based in Chandler, Arizona, and are an affiliate of Heritage Provider Network. As a leading value-based provider organization, we are committed to improving the quality of care, providing excellent member and provider experiences all while reducing cost.

The Claims Oversight and Compliance Manager ensures that claims processing aligns with federal and internal regulations. They conduct audits, develop Corrective Action Plan (CAP) responses, manage compliance reporting, health plan audits, and oversight of claims processing.

1. POSITION DUTIES & RESPONSIBILITES

• Data validation and submission of all health plan reports and deliverables
• Prepare and present audit packets for health plan audits
• Point of contact for health plan inquiries
• Interpret and implement timely updates to member denial letters, EOBs, and provider letters
• Develop CAP responses and ensure that changes are implemented timely and appropriately
• Regularly review claims processing, billing, and coding to identify compliance gaps and risks
• Oversight of audit functions for all claims processing teams, including offshore
• Oversight of all adjustment functions and reporting
• Ensures appropriate monitoring of PDR logs, provider inquiries, and call logs for timely completion
• Maintains contract rates in EZ Cap for appropriate claims adjudication
• Coordinates with Claims Manager regarding audit findings to ensure appropriate education and training is provided to Examiners
• Oversight of Audit and Adjustment teams to ensure timely review and adjustment of claims
• Coordinates requests for contract updates and system configuration.
• Collaborates with various departments to ensure system, documentation, and processes are up to date for appropriate claims adjudication.
• Ensure that departmental standards and timelines are met within each unit.
• Reviews time records, sets schedules and approves all vacation/time off requests for subordinate associates.
• Perform other duties as assigned

1. EDUCATION, TRAINING AND EXPERIENCE

• Bachelor's degree in healthcare administration or related field or equivalent work experience
• Minimum 5+ years in health plan/IPA claims processing, audit, or compliance roles
• Minimum 5+ years management experience
• Knowledge of Medicare rules, medical terminology, and managed care health plan rules and regulations, CPT, HCPCS, ICD-10, RVS codes
• Thorough understanding of claims operations to include payment of claims, interpretation of contracts; communication of benefits and eligibility
• Ability to draw upon knowledge and experience to anticipate issues, potential risks, implications, and changes to Medicare
• Strong math and analytical skills, including the ability to analyze and organize data
• Excellent ability to build and maintain business relationships with providers by providing prompt and accurate service
• Strong attention to detail
• Proficiency in Microsoft Office products, including Power Point, Word, and Excel
• Proven ability to lead team members in a positive and productive manner
• Demonstrated strong organizational, analytical, oral presentation, written communications, decision-making skills and leadership skills
• Must be able to work under general guidance of Claims Director with little direct supervision
• Strong knowledge of Medicare Billing & Payment Guidelines as well as CMS CCI Edits
• Familiar with all regulatory requirements including CMS
• Strong attention to detail
• EZ-Cap Experience is a plus
• Must be able to work independently, exercise judgment and communicate effectively.
• Must be able to work on computer systems, accessing multiple files and programs.

*This role requires 60 days FT in office presence, hybrid options will be available after the 60-day period.*