Claims Quality and Auditing Manager

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POST DATE 8/14/2019
END DATE 9/4/2019

Commonwealth Care Alliance Boston, MA

Boston, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree



Under the direction of the Vice President of Claims and Network Operations, Claims Quality & Auditing Manager is responsible for the management and oversight of CCA s prepay claims vendor. This is a new function at CCA and this position will be responsible for creating and implementing an efficient and effective claims quality and auditing process within the organization. This position is responsible for reviewing and investigating healthcare claims findings from the vendor. The Manager will be the main contact with the vendor and is responsible for building a collaborative working relationship. Being a Claims Quality & Auditing Manager, this position will manage all claims efforts with our vendor and develop claims auditing policies and procedures as well as a set of management reports to distribute to various levels of leadership. This position is responsible for planning, organizing and executing all activities as a result of the vendor s findings. A familiarity of FWA and TPL policies and procedures and experience investigating potential recoveries is preferred. The Manager works in concert with the Claims Management team as it relates to system and process improvements.


* Manages all claims efforts with claims pre-pay vendor.

* Responsible for investigating and reviewing all claims audit findings and making a determination on each.

* Collaborates with business owners to identify and fix root cause of findings to reduce errors and improve overall accuracy of claims processing while remaining in accordance with contractual and regulatory requirements.

* Responsible for identifying efficiencies and reduce manual processes.

* Reviews, modifies and creates claims policies and procedures as a result of claims findings.

* Recommends and implements process improvements to increase auto-adjudication rates.

* Possess a high level of expertise with medical and behavioral health claims adjudication process, fee schedules, contract terms, utilization management, coverage and reimbursement policies and claims processing standing operation procedures.

* Responsible for implementing a reconciliation process between CCA and vendor.

* Responsible for developing and implementing claims metrics related to claims audit findings.

* Responsible for development and regular delivery of cost savings reporting.

* Ensures compliance with CCA covered benefits and clams processing policies, procedures and contract terms.

* Contributes to the high-performance collaboration between CCA and its claims vendors.

* Provides clear documented instructions to our external vendor regarding payment rules and CCA processing policies as requested.

* Assists in development of claims processing documentation as well as reimbursement policies.

* Participates in cross-functional meetings, including external meetings with providers to discuss any ongoing claims issues.

* Communicates with providers to explain and resolve claims concerns.

* Various cross functional data integrity efforts.

* Liaison between Claims and other departments as needed.


* Bachelor's Degree.

* 3-5+ years in the following;

* 3+ years of supervisory experience;

* 3+ years of claims auditing/quality assurance role;

* 5+ years of processing claims, preferably Medicaid and/or Medicare claims;

* Solid understanding of CPT and ICD coding requirements.

* Coding certification preferred.

* Knowledge of Third Party Liability and Fraud Waste and Abuse issues.

* Strong leadership skills - Proven leadership skills and ability to build effective teams;

* Expert knowledge of industry standard claims processing policies and procedures;

* Excellent negotiation and conflict resolution skills; Excellent verbal and written communication skills;

* Intermediate knowledge of MS Office; Strong analytic and problem solving skills and ability to manage multiple projects and priorities.

* Standard office environment.

* Standard office equipment.

Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.