Job Type
Full-time
Description
POSITION SUMMARY
The Compliance Associate I is responsible for managing claim/complaint audits and assist with appeals, in compliance with audit requirements. The Compliance Specialist will work within the scope of responsibilities as dictated below with guidance and support from our Operations and Compliance leadership teams.
ESSENTIAL FUNCTIONS
- Manage claim/complaint audits and assist with appeals. Obtains information needed to ensure timely & accurate completion of audits, in compliance with audit requirements.
- Reviews medical records & billing-related documents for accuracy.
- Identifies discrepancies in patient records and/or documentation.
- Communicates with physicians’ offices to obtain patient records and all other information required by audit.
- Audits beneficiary files.
- Confirms patient eligibility standards.
- Contacts patients to verify data as necessary or required. Updates patient files.
- Complies with HIPAA rules, appropriately safeguarding PHI or other private & confidential information.
- Adapts quickly to frequent process changes and improvements.
- Is reliable, engaged, and provides feedback to improve processes and policies.
- Attends all department, team, and company meetings as required.
- Complete all tasks efficiently and in Timely matter.
- Embraces and exemplifies ADS core values:
- We put our people first
- We serve our members with passion
- We take ownership
- We pursue excellence
- We never stop growing
OTHER RESPONSIBILITIES
May perform any additional responsibilities or special projects as required.
Duties and responsibilities may be subject to change based upon the needs of the department.
Requirements
MINIMUM REQUIREMENTS
- High School diploma or equivalent
- Knowledge of insurance billing and processing claims
- Medicare claims and/or audit experience desired
- Familiarity with a variety of auditing & appeals processes and procedures
- Familiarity with healthcare compliance issues, including HIPAA privacy rules & requirements
- Proficiency in basic math and business calculations
- Working knowledge of computer/data entry with the ability to learn new systems
- Basic level of MS Office proficiency
EXPECTED COMPETENCIES
- Friendly, professional and effective communications skills; able to calmly present solutions in challenging situations
- Effective interpersonal skills
- Clear diction and knowledge of the English language, both written and verbal
- Service-orientation and aptitude to resolve challenges with audits and/or appeals
- Self-directed accountability and reliability
- Cultural competence
PHYSICAL DEMANDS
The physical demands described below 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 employees with disabilities to perform the essential functions.
While performing the responsibilities of the job, the employee is required to remain in a stationary position most of the time (stand or sit). While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel; and talk or hear. The employee is frequently required to stand, walk and reach with hands and arms. The employee is occasionally required to stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.
OTHER REQUIREMENTS
- Candidates must successfully pass a background check.
- Candidates must be able to provide proof of employment eligibility to work in the US.
