Health Plan Operations Manager

POSITION DETAILS AND DESCRIPTION


Title: Health Plan Operations Manager (Call Center Audit Lead)


Start date: ASAP


Duration: 6-12-month contract to hire


Location: PREFERS NYC but anywhere is okay


Pay Rate: $65/hr. C2C (Conversion salary around $135K)

General Job Description


Title: Health Plan Operations Manager (Call Center Audit Lead)
• Ideal candidate has come into a plan with poor auditing practices and analyzed gaps and redefined audit strategy, benchmarking, process, and team size to reimplement audit protocols and team to address claims quality/payment integrity issues.
• We are seeking a highly skilled and experienced professional to join our team as a Health Plan Operations Audit Expert with a specialization in Call Center and Claims Integrity Auditing for Medicare/Medicaid SNP (Special Needs Plan) claims.
• This role is critical in ensuring compliance with regulatory requirements, maintaining claims accuracy, and optimizing operational efficiency within our organization's health plan offerings.


Qualifications:
• Bachelor's degree in Healthcare Administration, Business Management, Finance, or related field; Master's degree preferred.
• Extensive experience (5+ years) in health plan operations, claims management, or auditing, with a focus on Medicare and Medicaid SNP claims.
• In-depth knowledge of Medicare and Medicaid regulations, policies, and procedures governing claims processing and billing.
• Proven track record of developing and implementing audit protocols, methodologies, and quality improvement initiatives.
• Relevant certifications (e.g., Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), Certified Internal Auditor (CIA)) preferred.


Responsibilities:

Claims Integrity Audit Management:
• Lead and oversee all aspects of claims integrity auditing processes for Medicare and Medicaid SNP claims.
• Develop and implement audit protocols, methodologies, and procedures to ensure comprehensive coverage and accuracy assessment.
• Conduct regular audits of claims data, documentation, and processes to identify discrepancies, errors, and areas for improvement.
• Collaborate with internal stakeholders, including claims processing teams, compliance officers, and data analysts, to address audit findings and implement corrective actions.


Regulatory Compliance Assurance:
• Stay updated on Medicare and Medicaid regulations, guidelines, and requirements related to SNP claims processing and billing.
• Interpret and apply regulatory standards to audit processes and ensure compliance at all stages of claims handling.
• Provide guidance and support to operational teams to align processes with regulatory expectations and minimize compliance risks.


Quality Assurance and Performance Improvement:
• Analyze audit findings and trends to identify systemic issues, root causes, and opportunities for enhancement.
• Develop and execute quality improvement initiatives to address identified gaps and enhance claims processing accuracy and efficiency.
• Monitor and evaluate the effectiveness of implemented solutions, measuring key performance indicators and metrics to track progress over time.


Documentation and Reporting:
• Prepare comprehensive audit reports documenting findings, observations, recommendations, and action plans.
• Present audit results and insights to senior management, regulatory authorities, and other relevant stakeholders as needed.