Director, Claims Compliance and Audits

Salary Range: $135,136.
00 (Min.
) - $175,676.
00 (Mid.
) - $216,218.
00 (Max.
) Established in 1997, L.
A.
Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents.
We are the nation’s largest publicly operated health plan.
Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.
A.
Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
Job Summary The Director of Claims Compliance and Audit has overall responsibility and accountability for all aspects of claims compliance and claims audit operations.
This position is responsible for facilitating and promoting effective cross-functional collaborations with stakeholders to monitor and improve end-to-end quality for LA Care (LAC).
The position is responsible for the functions to measure, monitor, and enhance quality across the organization.
This position is responsible for ensuring the Claims Audit productivity metrics are monitored to ensure the timely and accurate audit of claims and ensure they are being processed in compliance with regulatory requirements and organizational expectations.
The Director is responsible for performing recurring claim-level audits, reporting quality results and dashboards, and working cross-functionally to leverage the quality data to continually improve overall quality results.
The position is responsible for overseeing the related quality review and analysis of organizational initiatives, projects, etc.
In addition, the Director ensures compliance with all Department of Managed Health Care (DMHC), Medi-Cal, federal and state regulations.
This is achieved by participating in the annual audits, both internal and external and continuous oversight of the Claims Operations, Payment Integrity, and Electronic Data Exchange (EDI) processes and metrics as well as other related managed care services activities.
This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.
Duties Develop an overall quality program for claims processing.
Measures the end-to-end performance, presents quality results to senior and executive leaders, works cross-functionally to develop quality improvement plans, and monitors quality results post deployment.
Reviews, analyzes, and supports execution of enhancements to impact the overall claims payment accuracy.
Works to improve visibility to quality performance across the organization and develops dashboard reporting to monitor results, provides timely feedback at the operational and staff level, works cross-functionally to develop and maintain examiner-level scorecards including key quality measures, and takes action based performance data.
Implement and operationalize a monitoring program for initiatives post-deployments to measure results and validate expected outcomes.
Leads a team and engages the staff in developing a high-performing quality team.
Provides guidance to ensure that Claims Integrity efforts are performed with the highest and most current rules, regulations, policies, business rules and industry standards.
Collaborates with various internal and external stakeholders and peers to identify, develop, prioritize, implement tactical plan, Ensure quality resolution and improve process/system enhancements, training, and policy review/updates.
Ensures that projects are completed on time and within budget.
Participates in special projects, committees, audits, etc.
Leads efforts for defining processes, workflows, expected outputs, etc.
to support quality best practices and manage programs across LA Care (LAC).
.
Collaborates with various internal and external stakeholders and peers to develop and implement tactical plans to improve overall quality which may include process/system enhancements, training, and policy review/updates.
Ensures that projects are completed on time and within budget.
Participates in special projects, committees, audits, etc.
Duties Continued Responsible for the development, implementation, and monitoring of training and documentation plans.
Leads efforts for defining processes, workflows, expected outputs, etc.
to support quality best practices and manage programs.
Effectively leads and/or participates on teams focused on improving the quality of claims data, provider data, payment accuracy, and system configuration.
Supports Senior Leadership by serving as SME for a deep understanding of all managed care contracts and payment rules; establishing strong relationships with internal and external stakeholders to define, align, and deliver specific Claims Integrity initiatives; and, by participating in organizational strategy, development, and gap analysis activities to identify incremental Claims Integrity opportunities.
Leads projects relative to new compliance initiatives or processes.
Evaluate new and revised regulations.
Develop, revise and validate processes and metrics to meet regulations.
Direct the reviews of claims process, validation and control reports impacting claims operations compliance.
Lead all internal and external audits including development of corrective actions.
Oversee Corrective Actions to ensure all target dates are met.
Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.
Performs additional duties as assigned.
Education Required Bachelor's Degree In lieu of degree, equivalent education and/or experience may be considered.
Education Preferred Experience Required At least 7 years of healthcare (Medicare, Medicaid, Commercial) claims experience with 5-7 years of supervisory/management experience.
Proven track record of claims quality improvement.
Extensive experience in overseeing and monitoring the timeliness and accurate processing of claims.
Extensive experience working with Coordination of Benefits (COB) and Third Party Liability (TPL) claims in a managed care setting.
Must be highly experienced in interpreting complex contractual terms with Providers, Facilities, Plan Partners, delegated groups and related contractual scenarios.
Skills Required: Strong interpersonal leadership skills.
Extensive knowledge in Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), ICD-9, ICD-10, Medicare, and Medicaid rules and regulations.
Deep study and understanding of managed care contracts and payment rules.
Strong project leadership and management skills required; ability to prioritize, plan, and handle multiple tasks/demands simultaneously.
Knowledge of Microsoft Office suite, including Word, Excel and PowerPoint.
Excellent interpersonal, verbal, and written communication skills required.
Must be highly collaborative and maintain a consultative style with ability to establish credibility quickly with all levels of management across multiple functional areas.
Excellent verbal, written communication and presentation skills.
Must be able to present findings to various levels of management, across all organizations.
Licenses/Certifications Required Licenses/Certifications Preferred Certified Professional Coder (CPC) Required Training Physical Requirements Light Additional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market.
The range is subject to change.
L.
A.
Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)