Senior Compliance Claims Auditor, Data

At Collective Health, we’re transforming how employers and their people engage with their health benefits by seamlessly integrating cutting-edge technology, compassionate service, and world-class user experience design.

The Compliance Claims Auditor's primary focus will be supporting the Company's internal compliance operations by developing and strengthening Collective Health's claims compliance program. If you are a compliance professional excited about helping build and operate a broad range of corporate and healthcare compliance functions at a mission-driven, healthcare technology company, then this role is for you! You will work on assuring the accuracy of claims processing performed by Collective Health. You will build relationships across all parts of the business and drive cross-functional initiatives to continuously improve our compliance program and support the Collective Health compliance team. This role reports to the Director of Compliance and works cross-functionally with various internal teams. The Compliance Team is responsible for providing oversight over the claims processing systems and procedures at Collective Health and serving as a thought and innovation partner to business and corporate functions as they implement new initiatives.

• Create electronic claims accuracy monitoring mechanisms utilizing claims data models to identify potentially non-compliant claim adjudications.
• Develop and implement automated claims audits utilizing purposeful review of claims patterns and data analytics to proactively identify adjudication inaccuracies.
• Work cross-functionally with data analytics, data engineering, and other operational teams to identify and remediate claims errors based on data patterns.
• Audit medical claims received from providers for adjudication accuracy, including professional and institutional claims.
• Manage internal and external audits.
• Provide timely input on compliance-related issues and guidance requests.
• Assist with compliance risk assessments and audit readiness.
• Assist with new compliance regulation implementation related to claims accuracy.
• Collaborate with team members to identify and mitigate compliance risk for claims.
• Work closely with Collective Health attorneys to receive and coordinate legal guidance needed to operationalize important initiatives and requirements.

• Bachelor's degree or equivalency required, preferably in a business, technology, or healthcare field.
• At least 8 years of experience performing data analyses on complex medical claims data sets, including but not limited to performing impact analyses and automated (electronic) claims reviews.
• A coding credential is required, preferably AHIMA CCS, or CPC, CPC-A, RHIT. Preference is given to candidates with a CHDA.
• Broad experience and knowledge of coding and reimbursement systems (MS-DRGs, PPS Systems, bundled payments, OPPS, value-based care, FFS).
• Broad experience and knowledge of healthcare and healthcare business practices and principles.
• Broad experience and knowledge of third-party payer practices, including precertification, timely filing, claims processing, coverage, and payer rules.
• Broad experience and knowledge of healthcare claims data and analytics.
• Knowledge and applicable understanding of federal laws related to ERISA group health plans and state department of insurance laws.
• Knowledge of the 5010 data standards, along with practical understanding of EDI transmission files (835/837, 270/271, etc.) and all X12 data specifications.
• Knowledge and applicable understanding of subrogation, coordination of benefits, and claims hierarchy standards.
• Knowledge and applicable understanding of state and federal laws which apply to claims processing for group health plans, such as the No Surprises Act, ACA Preventive Health Provisions, parity laws, etc..
• Experience developing or enhancing a compliance program is desired.
• A CHC certification is preferable.
• Proven ability to build relationships and to collaborate effectively with a broad range of stakeholders and departments to drive compliance-friendly and business-friendly outcomes.
• Strong organizational and project management skills with demonstrated attention to detail.
• Proficiency with technology tools, including Google Drive, Sheets, Docs, Box, Smartsheet, Looker, Slack, and Databricks.
• Critical thinking and decision-making skills, with the ability to quickly determine issues that need escalation.
• Excellent written and verbal communication skills (including presentations) and the ability to drive execution in a team environment.

This job can be performed in a location where we have an office: San Francisco, CA, Lehi, UT, or Plano, TX, with the expectation of being in office at least two weekdays per week, or hired for remote work in the following states: AZ, CA, CO, CT, FL, GA, IL, MD, MA, MI, MN, NV, NJ, NY, NC, OH, OR, TN, TX, UT, VA, WA, or WI.

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the salary, you will be eligible for stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.