Claims Quality Audit Director jobs in Berkeley, CA

About Our Company

At Altais, we're looking for bold and curious innovators who share our passion for enabling better health care experiences and revolutionizing the healthcare system for physicians, patients, and the clinical community. Doctors today are faced with the reality of spending more time on administrative tasks than caring for patients. Physician burnout and fatigue are an epidemic, and the healthcare experience and quality suffer as a result. At Altais, we’re building breakthrough clinical support tools, technology, and services to let doctors do what they do best: care for people. We invite you to join our growing passionate team as we change the game for the future of healthcare and enable the experience that people need and deserve. Altais family of companies include: Brown and Toland Physicians, Altais Medical Group Riverside, and Family Care Specialists.

About Your Team

Are you looking to work with a high performing, fast growing and dynamic Operations Integrity team? Altais and our subsidiaries, form one of the most recognized medical groups in California. We are 4,000 physicians, working in over 40 cities in California, caring for more than 500,000 patients. If working in a mission driven organization supporting highly competent, hard-working, thoughtful clinicians who value good ideas and are passionate about reshaping healthcare excites you, then we are thrilled to welcome you to your new career.

This position is located in our brand-new Oakland City Center location, or remotely (within the state of California). We are flexible provided you are open to traveling to the Oakland office locations as needed. 

About Your Work

As the Claims Quality Assurance Auditor, you will be responsible for reviewing claims transaction audit reports, perform claims adjudication quality review to assure compliance with health plan audits. Complete daily, weekly and monthly audits.  As part of a cross-functional team, you will work directly with various areas within the organization.

You will focus on:

• Responsible for reviewing claims transaction audit reports, perform claims adjudication quality review to ensure compliance with health plan audits. Complete daily, weekly, and monthly audits. Perform daily review of focused pre-payment audit reports and daily review of claims audit work queues.  
• Provides technical assistance on special projects, utilizing ability to interpret claims policies, including analysis and functional claims testing support for vendor contract implementation and system upgrades.
• Develops and provides statistical data on individual employee errors and conducts analytical research to effectively solve processing issues. Identify error trends for specific training needs in claims and adjustment areas.  
• Facilitate and manage internal and external audits. Organize and submit requested audit documentation. Develop and document corrective action plans as needed.
• Oversee and coordinate Claims training programs, to include review and approval of authored training documents and curriculum.

The Skills, Experience & Education You Bring 

• Demonstrated thorough knowledge of medical claim processing procedures/systems and a thorough understanding of claim protocols, industry standards and CMS regulations as it relates to claims processing, correct coding, and compliance.
• Demonstrated intermediate proficiency in MS Office products, with an emphasis in Word, Excel
• Demonstrated strong oral and written communication skills, professional approach to problem resolution, strong organizational skills with ability to prioritize projects, strong financial analytical skills with attention to detail.
• Demonstrated strong ability of independent decision-making skills and demonstrated ability to take initiative to resolve issues.
• Five (5) or more years prior claims processing experience in an IPA or HMO related setting; eight (8) or more years preferred.
• Two (2) years Knowledge of Epic/Tapestry claims systems preferred.
• Five (5) or more years knowledge of and working experience with ICD-10, CPT and HCPC coding systems. 
• High school graduate or GED and equivalent of eight (8) years in Claims.  
• Some college or Associates degree from an accredited school

Altais values the contribution each Team Member brings to our organization. Final determination of a successful candidate’s starting pay will vary based on several factors, including, but not limited to education and experience within the job or the industry. The pay scale listed for this position is generally for candidates that meet the specified qualifications and requirements listed on this job description. Additional pay may be determined for those candidates that exceed these specified qualifications and requirements. We provide a competitive compensation package that recognizes your experience, credentials, and education alongside a robust benefits program to meet your needs.

The anticipated pay range for this role is listed in our salary posting for transparency but may vary based on factors including the candidate’s qualifications, skills, experience, and geographic location. This base pay range is specific to California and can vary based on Bay Area, Metro LA, and Greater California regions which may not be applicable to other locations.

Altais and its subsidiaries and affiliates are committed to protecting the privacy and security of the personal information you provide to us. Please refer to our ‘CPRA Privacy Notice for California Employees and Applicants’ to learn how we collect and process your personal information when you apply for a role with us.

Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork – Activity level: Sedentary, frequency most of workday.

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.