Compliance Clerk

Summary

The Compliance Coordinator will be responsible for ensuring each department is compliant with CMS and DMHC regulations and Company administrative policies and guidelines.

Duties and Responsibilities

• Provide support to management to ensure that all claims and regulatory responsibilities are met - including claims timeliness reports, universal listings and regulatory audits.
• Research and gather documentation to assist in providing resolution of non-compliance issues.
• Liaison with managers of each business unit to determine whether departments are operating efficiently, as well as to recommend improvements for internal controls.
• Assist in development and review of policies and procedures to ensure they are up to date and compliant with CMS and DMHC regulations.
• Maintains contact with applicable health plan agencies/organizations for guidance in the solution of compliance issues.
• Manages internal projects and/or programs by discussing plans, recommendations, and/or findings.
• Audits regulatory guidelines for denial accuracy and timeliness of claims.
• Assist with organizing audits including pulling all required data and performing a preliminary audit review with Compliance Manager.
• Research and respond to Corrective Action Plans when deficiencies are identified by the Health Plans.
• Participates in department staff meetings.
• Other duties as assigned by the Compliance Manager.

Qualifications

• AA degree
• 1 – 3 years work experience in Compliance or compliance auditing in a health plan or managed care environment.
• Experience in medical terminology, ICD-10 coding, CPT coding, and knowledge of federal billing and reimbursement guidelines.
• Working knowledge of healthcare compliance regulations with CMS and DMHC.
• Project management skills.
• Ability to draft and revise documents including policies, standards, analyses, and reports.
• Computer literacy required, including proficient use of Microsoft Word, Excel, and Outlook. EZ-CAP is a plus.
• Typing skills of at least 40 wpm.