Claims Audit Analyst - Denver Health Medical Plan (Must Live in Colorado. Weekly On-Site Requirement)

About the role

We are recruiting for a mission-driven Claims Audit Analyst - Denver Health Medical Plan (Must Live in Colorado. Weekly On-Site Requirement) to join our team!

We're with you for life's journey. At Denver Health, purpose isn't just something we believe in-it's something we live every day, for life's journey.

Job Summary

Under general supervision, Claims Audit Analyst is responsible for benefit administration and assist with the daily management of claims inventory. Daily data analysis and research of claims processing to ensure benefit structures and operation processes are adhering to the rules, regulations and contractual requirements by CMS, DOI, contracted and non- contracted providers.

Oversee the daily management of claims inventory through Business Management Services (BMS) for issue escalations or resolutions. Serves as liaison between users of the software and technical staff (BMS and IS). Work in conjunction with the Compliance program to monitor and detect potential claims for fraud and abuse.

This position will interact will all levels of management and employees.

Essential Functions

• Accurately perform audits on claims processed by the vendor. Perform special claims audits as assigned. Perform calibration "audit the auditor" assessments and share findings. 30%

Additional information

• *Review provider escalations and ad-hoc member/provider grievance and appeal reviews to address possible payment errors. Escalate any needed configuration changes. 20%
• *Monitor member accumulators and log on Smartsheet any overage to Member Maximum Out of Pocket limits. Work with vendor to root cause & resolution
• 10%
• *Address specific pricing needs including but not limited to: transplant pricing, DRG downcoding, NSA claims. 10%
• *Review IDR NSA disputes, conduct greater of QPA reviews, log cases to Smartsheet, offer in compromise, route any arbitration cases for further assessment/completion. 10%
• *Conduct weekly check run reviews for abnormalities for all plans based on summary reports to ensure that claim payments are adhering to the rules, regulations and contractual requirements. 10%
• *Ad hoc work as required, including supporting the Claims Manager with data and analysis. 10%

Education

• Bachelor's Degree required
• OR -
• High school diploma or GED required AND an additional 4-6 years of claims experience in lieu of degree required

Work Experience

• 1-3 years claims experience required
• OR -
• Minimum of five years of claims experience without Bachelor's degree required

Knowledge, Skills and Abilities

• Thorough knowledge of QNXT and benefit structure to ensure claims accuracy.
• Ability to define problems, collect data, establish facts and draw valid conclusions.
• Knowledge of all claim forms and coding types, including UB-04, CMS1500, ICD-9-CM, CPT-4, ICD-10-CM, HCPC, Revenue and NOC coding. HIPPA, HEDIS.
• Experience with Medicare, Medicaid and Commercial programs preferred.
• Extensive knowledge of claims administration in a healthcare field.
• Ability to lead/manage projects and interact with staff on all levels.
• Able to implement testing material for changes with benefit structures for all lines of business.
• Interact and collaborate with other corporate groups such as Provider Relations, Member Services, Information Systems, Compliance, Third Party Recovery, Finance, Patient Accounts, Enrollment, Utilization Management and Product Line Managers.
• Key candidate will be adaptable; detailed oriented and have strong analytical skills.
• Excellent verbal and written communication skills.
• Access database, Reports, Queue's and other tools as needed.
• Total Claims Capture and Control (TC3) experience preferred.
• Working knowledge of CMS/Medicare payment platforms a plus including the Resource Based Relative Value System (RBRVS) and Diagnostic Related Groups (DRG).
• Proficiency in Word, Excel, Webstrat, PowerPoint, Business Intelligence Portals and Audit Tool.
• Must Live in Colorado
• Shift
• Days (United States of America)
• Work Type
• Regular
• Salary $60,500.00 - $87,700.00 / yr

Benefits

At Denver Health, we take care of the people who take care of our community. Our benefits are built to support your life, your family, and your future - with generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs.

We invest in your growth through tuition assistance, career advancement pathways, and professional development - while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health, you're joining a mission-driven organization that invests in you.

Here is a small list of our benefit programs

• Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays
• 100% paid parental leave up to 6 weeks
• Immediate eligibility for retirement plans with employer contribution up to 9.5%
• Generous medical, dental, vision plans in addition to employer paid disability and life insurance.
• Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center
• Free RTD EcoPass (public transportation)
• Childcare discount programs & exclusive perks on large brands, travel, and more
• Tuition reimbursement & assistance
• Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways
• Professional clinical advancement program & shared governance
• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program
• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer