Claims Quality Audit Director jobs in Parkersburg, WV

Claims Quality Audit Director directs and oversees the operations of the claims quality audit department to follow the audit policies, procedures and regulation. Provides professional knowledge and guidance on technical or procedural problems. Being a Claims Quality Audit Director creates claims audit policies and procedures. May recommend changes in claims processing procedures. Additionally, Claims Quality Audit Director typically Requires a bachelor's degree. Typically reports to top management. The Claims Quality Audit Director manages a departmental sub-function within a broader departmental function. Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure. To be a Claims Quality Audit Director typically requires 5+ years of managerial experience. Deep knowledge of the managed sub-function and solid knowledge of the overall departmental function. (Copyright 2024 Salary.com)

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Claims Audit Specialist - Peak Health
  • Allied Health Solutions
  • Morgantown, WV FULL_TIME
  • Welcome! We're excited you're considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you'll find other important information about this position.

    Come join our Peak Health team at WVU Medicine as an Claims Audit Specialist (IAC), contributing to the foundation for an innovative, new Medicare Advantage health plan. This position will report to the Director of Claims Operations, playing a unique and important role in our mission to change healthcare for the better.
    Experience in the healthcare industry, medical and pharmacy claims monitoring, critical thinking, and attention to detail will help this role build an effective and efficient audit and oversight function. The Claims Audit Specialist will work with Peak leadership to create, implement, and oversee the medical and pharmacy claims audit and reporting process, collaborating with Compliance as needed.
    This role will be instrumental in medical and pharmacy claims implementation from an audit perspective. You will work with management and peers on the Peak team to build the audit process and perimeters, along with a formal reporting structure. You will evaluate processing quality, while developing coaching and training to address issues.

    MINIMUM QUALIFICATIONS:

    EDUCATION, CERTIFICATION, AND/OR LICENSURE:

    1. Bachelor's Degree, or greater in related Healthcare field.

    EXPERIENCE:

    1. Two (2) years of experience working with audits in a health care capacity.

    2. Five (5) years of medical and pharmacy claims and adjustment processing experience.

    3. One (1) year of provider/member file maintenance experience.

    PREFERRED QUALIFICATIONS:

    EDUCATION, CERTIFICATION, AND/OR LICENSURE:

    1. Master's Degree, or equivalent experience, in related healthcare field.

    EXPERIENCE:

    1. Seven (7) or more years in a medical and pharmacy claims processing and audit environment.

    2. Three (3) or more years with audit or quality control oversight.

    3. Three (3) or more years of mentoring and/or training experience.

    4. Two (2) or more years of formal audit response experience. (CMS, SOX, etc.)

    5. Two (2) or more years of familiarity with member and provider contract structure and file maintenance.

    6. At least one (1) or more years of quality report creation and implementation experience.

    CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

    1. Creates and conducts regularly scheduled audits of claims team processes and outputs.

    2. Creates and conducts regularly scheduled audits of claims team adherence to production metrics.

    3. Assesses claims staff production and quality within department standards.

    4. Creates, Implements, and Presents audit reports on the compliance of claims processing guidelines.

    5. Effectively communicates with internal and external staff.

    6. Elevates issues to next level of supervision and Compliance, as appropriate.

    7. Develops and conducts staff training on any audit issues as needed.

    8. Attends all required training classes, demonstrating proficiency and high ability to learn.

    9. Other duties as deemed appropriate by the Management Team.

    PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

    1. Ability to sit for extended periods of time.

    2. Ability to answer phone calls for extended periods of time.

    WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

    1. Standard office environment with electrical equipment (i.e., telephone, personal computer, copier, fax machines, etc.)

    2. Computer Software/Systems include but not limited to Microsoft Office Professional Suite (Outlook, Word, Excel, Access) Internet Explorer and EPIC

    SKILLS AND ABILITIES:

    1. Working Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.

    2. Ability to take direction and to navigate through multiple systems simultaneously.

    3. Excellent written and oral communication, interpersonal skills, and telephone etiquette.

    4. Ability and patience to provide coaching and training to claims processing staff.

    5. Ability to keep precise, detailed reports on audit and training activity.

    6. Attention to detail and organizational skills.

    7. The ability to communicate clearly, concisely, and articulately both in oral and written forms.

    Additional Job Description:

    Scheduled Weekly Hours:

    40

    Shift:

    Exempt/Non-Exempt:

    United States of America (Exempt)

    Company:

    PHH Peak Health Holdings

    Cost Center:

    2501 PHH Risk Admin

    Address:

    1085 Van Voorhis Rd

    Morgantown

    West Virginia
    Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.

    The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

     

  • 24 Days Ago

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Director of Nursing DON
  • Quality Care LTC
  • Woodsfield, OH FULL_TIME
  • Competitive compensation package! Warm and supportive team!Lionstone Care Management is seeking a highly motivated and passionate leader to direct our team of quality care providers in our Woodsfield,...
  • 2 Days Ago

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Quality/Risk Director
  • EasyHiring
  • New Haven, WV FULL_TIME
  • We are an EasyHiring recruiting company that is looking for candidates for our partners for the position of Quality/Risk Director in New Haven, WV for work in Parkersburg, West Virginia.TheQuality/Ris...
  • 19 Days Ago

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Cdl driver hazmat
  • Quality Carriers
  • Athens, OH FULL_TIME
  • Seeking CDL-A Truck Drivers $1,700 Week / Avg Home Every Other Night. N - Tanker Vehicles Endorsement. H - Hazardous Materials Endorsement. Compensation $1,700 weekly average Bonuses $3,000 transition...
  • 2 Days Ago

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Class-A CDL Regional Company Driver
  • Quality Carriers
  • Washington, WV FULL_TIME
  • Class-A CDL Regional Company DriverWASHINGTON, WVResponsibilitiesRequirements: Valid CDL-A With Tankers and Hazmat Endorsements Must-Have or Be Willing to Obtain TWIC Card 1 Year Tractor Trailer Exper...
  • 2 Days Ago

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Remote Claims Writer
  • Metro Public Adjustment
  • Morgantown, WV FULL_TIME
  • Job Description:The position we are hiring for is customer/client relations. In this position you will be writing claims and submitting the paperwork. Duties can be performed remotely. Company Informa...
  • 22 Days Ago

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0 Claims Quality Audit Director jobs found in Parkersburg, WV area

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VP Quality and Patient Safety
  • West Virginia University Health System
  • Parkersburg, WV
  • Welcome! We're excited you're considering an opportunity with us! To apply to this position and be considered, click the...
  • 3/28/2024 12:00:00 AM

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Assistant Director of Nursing - ADON - RN
  • Genesis Healthcare
  • Parkersburg, WV
  • Benefits*Nursing Student Loan Debt Repayment and Tuition Assistance*Variable compensation plans*Tuition, Travel, and Wir...
  • 3/28/2024 12:00:00 AM

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Staff Development Coordinator - RN
  • Genesis Healthcare
  • Parkersburg, WV
  • Willows Center seeks full time, day shift, Nurse Practice Educator to join our team. Monday through Friday schedule, on ...
  • 3/28/2024 12:00:00 AM

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Director of Nursing - DON - RN
  • Genesis Healthcare
  • Parkersburg, WV
  • Benefits*Nursing Student Loan Debt Repayment and Tuition Assistance*Incentive compensation plan*Tuition, Travel, and Wir...
  • 3/28/2024 12:00:00 AM

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Director of Quality Assurance - Pharmaceutical
  • Management Recruiters of Edison
  • Albany, OH
  • Our client a growing pharmaceutical company with multiple plants in the US, needs a Director of QA at their new Ohio pla...
  • 3/26/2024 12:00:00 AM

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Production Supervisor
  • Candidate Select
  • Mason, WV
  • Market leading, multibillion dollar, award winning global consumer packaging company seeks to add an incredibly talented...
  • 3/26/2024 12:00:00 AM

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Quality Director
  • Wedgewood
  • Albany, OH
  • Job Details Level Management Job Location Albany - Albany, OH Position Type Full Time Education Level 4 Year Degree Trav...
  • 3/25/2024 12:00:00 AM

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Production Supervisor
  • Hi-Vac Corporation
  • Marietta, OH
  • Job Description Job Description Hi-Vac Corporation is seeking a talented and experienced candidate for a supervisor role...
  • 3/24/2024 12:00:00 AM

Parkersburg is a city in and the county seat of Wood County, West Virginia, United States. Located at the confluence of the Ohio and Little Kanawha rivers, it is the state's third-largest city and the largest city in the Parkersburg-Marietta-Vienna metropolitan area. The population was 31,492 at the 2010 census. Its peak population was 44,797 in 1960. The city is about 14 miles south of Marietta, Ohio. The Baltimore and Ohio Railroad reached Parkersburg in 1857, but lacked a crossing over the Ohio River until after the American Civil War. When the B&O completed the Parkersburg Bridge (CSX) 18...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Claims Quality Audit Director jobs
$134,249 to $191,854
Parkersburg, West Virginia area prices
were up 1.2% from a year ago

Claims Quality Audit Director in Olympia, WA
Based on our compensation data, the estimated salary potential for Claims Quality Audit Director will increase 16 % over 5 years.
December 23, 2019