GOLD KIDNEY CORE VALUES:

Gold Kidney Health Plan is a people business. Our success depends on having the best and brightest employees and helping them attain their personal and professional goals while delivering excellence in patient care and business results. Our employees embody our culture, which is based on six core values supporting our promise to improve the quality of life of every patient every day. These core values are Patients and Partners First, Honesty and Integrity, Quality and Compliance, Collaboration, No-Limits Mindset and Results Oriented.

Purpose and Scope:

Perform end to end operational audits and assist in the development of value-added feedback regarding the potential negative impact to claims accuracy. Investigate and report conflicts and/or variances of operational processing guidelines that are not compliant with Federal regulations and/or executed provider contracts.

Principal Duties and Responsibilities:

• Research statutory requirements and ensure compliance of all operations that impact claim accuracy.
• Conduct audit interviews with front line staff in all functional areas that fall under claim operations.
• Test, create flow charts and map operational processes that touch the outcome of claims accuracy.
• Evaluate internal processes and/or controls to identify non-compliance issues and improvement opportunities.
• Create audit memos to document audit findings, which will result in audit recommendations, reports, and claims audit criteria enhancements.
• Responsible for Claims payment accuracy is 99% or greater.
• Proactively communicate and collaborate with key stakeholders to analyze information needs and documentation needed.
• Proactively communicate and collaborate with key stakeholders to analyze information needs and documentation needed.
• Duties as assigned

Desired Competencies

• Customer Focus
• Organizational Skills
• Time Management
• Quality Management
• Problem Solving
• Collaboration
• Communication Proficiency
• Leadership
• Presentation Skills

Physical Demands and Working Conditions:

• Ability to view the computer screen for long periods of time.
• Exerting up to 20 pounds of force occasionally and/or a negligible amount of
  force frequently or constantly to lift, carry, push, pull, or otherwise move
  objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

Supervision:

• This position does not have supervisory responsibilities.  

Education:

• High School Diploma required.
• Graduate of Medical Assistant program; Medical Assistant certification preferred.

Experience and Required Skills:

• 2+ years of auditing or accounting experience.
• 4+ years of Medicare claims processing systems and the ability to interpret state and provider contracts.
• Proven written and oral communication skills.
• Demonstrated team building skills.
• Excellent verbal, analytical, organizational, and written skills.
• Intermediate level of proficiency with MS Excel and Word.