What you'll be doing

• Conduct routine monitoring and audits of procedures, including but not limited to billing systems audits, Encounter submission audits, and client audits.
• Understand and stay current with client contract criteria and requirements ensuring client services are compliant as well as meet client expectations.
• Understand and stay current with Medicare Advantage requirements and ensuring systems are compliant as well as meet client expectations
• Assist with all required Commercial andMedicare Advantage claims reporting
• Assist Manager with annual delegated Medicare Advantage and Commercial audits.
• Confirm pricing are correct in the fee tables after the downloads are complete.
• Monitor internal and external processes to detect any practices that, either directly or indirectly, result in fraud, abuse or waste that results in unnecessary costs.
• Assist with the submissions, appeals and UM Challenges for Reinsurance process.
• Run access queries as needed for administrative purposes.
• Assist coworkers and Internal Auditors in additional compliance and auditing responsibilities.
• Consistently exercise independent judgment and discretion in matters of significance
• Other duties and responsibilities as assigned

What success looks like...

• ...in 3 months
• Intermediate knowledge on the Claims processes within claims processing software.
• Novice understanding of Encounter Submission audits and processes.
• Novice to Advanced knowledge of all BCBS Medicare Advantage report requirements and the required data to be submitted
• Novice understanding of authorization requirements.
• Consistently performs daily, weekly, monthly audits.
• ...in 6 months
• Create impact reports for errors found in Health Planaudits.
• R eport audit findings to department managers for coaching, mentoring and tracking of audit percentages.
• Consistently and accurately assist in encounter submission audits and Medicare Advantage reporting requirements.
• ...in 12 months
• Intermediate understanding of UM Challenges and Reinsurance audits and appeals.
• Novice knowledge of external payor audits.
• Identify the need for higher level system enhancements as report and claim requirements evolve and/or change.
• Bring forward new ideas, audits and processes

What you'll need to have

• Minimum 3-5 years of experience in the healthcare or managed care industry, including claims/reimbursement experience, professional analytics-related experience and experience working on/managing major projects.
• Minimum 1-3 years of Medicare Advantage HMO experience in the healthcare or managed care industry, including claims/reimbursement experience, auditing, professional analytics-related experience and experience working on/managing major projects.
• Minimum 3 years auditing experience in the healthcare industry.
• CPT and ICD coding knowledge.
• Knowledge of Medicare requirements and APC Pricing knowledge.
• Advanced to expert proficiency in the Microsoft Office products, especially Microsoft Word, Microsoft Excel & Microsoft Access.
• Successfully function as an Internal Claims Auditor
• Able to problem solve, exercise initiative and make medium to high level decisions.
• Thorough understanding of current federal, state and local healthcare compliance requirements.
• Ability to meet deadlines and prioritize tasks; collect, correlate and analyze data.
• Ability to work independently with minimal supervision and as part of a team.
• Must be organized, self-motivated, detail-oriented, disciplined, professional, and a team player.
• Effective written and oral communication

What we'd love for you to have

• Bachelor's degree in healthcare informatics, business administration, or related field, or equivalent in experience and education.
• Medicare Advantage HMO experience in the healthcare or managed care industry, including claims/reimbursement experience, auditing, ODAG/Part C Reporting, professional analytics-related experience and experience working on/managing major projects.
• Certified Professional Coder strongly recommended or willing to obtain within 6 months of hire.
• Experience and knowledge with Medicare Advantage strongly encouraged.
• Prior claims processing experience within Eldorado HealthPac Claims Adjudication System is a plus.
• Claim coding experience, coding edits experience and APC Pricing knowledge.
• CPT and ICD coding knowledge

What you get

• Learn the life of a Contract Management firm with Independent Physician Associations across Illinois.
• Encouragement to bring ideas to the table.
• Be an integral part of a desired team within Arcadia's Value Based Services.
• Expand your claims processing knowledge to the "behind the scenes" aspect.
• Opportunity to be part of a team creating automated processes to drastically improve healthcare.
• Extraordinary and flexible work environment and culture.
• Amazing benefits package including flexible time off.
• Receive cash compensation with health, dental, and other benefits.

This position is responsible for following all Security policies and procedures in order to protect all PHI under Arcadia's custodianship as well as Arcadia Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.
About Arcadia
Arcadia.io helps innovative healthcare systems and health plans around the country transform healthcare to reduce cost while improving patient health. We do this by aggregating massive amounts of clinical and claims data, applying algorithms to identify opportunities to provide better patient care, and making those opportunities actionable by physicians at the point of care in near-real time. We are passionate about helping our customers drive meaningful outcomes. We are growing fast and have emerged as the market leader in the highly competitive population health management software and value-based care services markets, and we have been recognized by industry analysts KLAS, IDC, Forrester and Chilmark for our leadership. For a better sense of our brand and products, please explore our website , our online resources , and our interactive Data Gallery .
This position is responsible for following all Security policies and procedures in order to protect all PHI under Arcadia's custodianship as well as Arcadia Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.