Medical Claims Review Manager jobs in Raleigh, NC

Payment Integrity Client Success Specialist

Remote

Who We Are:

Constellation Quality Health, formerly CCME, is a non-profit health care quality organization and QIO-like Entity certified by the Centers for Medicare & Medicaid Services (CMS) founded by physicians in 1983. Headquartered in North Carolina’s Research Triangle, we offer an array of quality improvement, clinical review, audit, technical, and consulting services and solutions to improve care delivery, system performance, and patient outcomes.

What You’ll Do:

We are seeking a Payment Integrity (PI) Client Success Specialist to ensure required contract deliverables are timely and accurate for delivery to the Director and determine staff needs and requirements. The Specialist is responsible for assisting with the development of new client relationships through outreach, conference attendance, networking, and business associations and assisting with development and execution of plans to increase company, program visibility, and relationship building.

We expect you to:

• Assist with monitoring team key performance indicators such as productivity, schedules, volume, and accuracy/ timeliness of deliverables.
• Assist with developing training materials, tools, and guidelines for team members, potential customers, and providers on review.
• Assist Payment Integrity Director (Director) as needed to maintain budget targets.
• Provide excellent customer service and assist with identifying and implementing innovative customer solutions; research and resolve provider inquiries, and/or complaints related to services provided.
• Assist in the development of program operations manuals and reports and in the design, preparation, and submission of weekly and monthly reports.
• Collaborate and assist as requested by Director with Information Technology (IT) development and workflow implementation for data collection, tracking, notification, and reporting as required.
• Coordinate with Program Integrity managers to conduct independent research to assist with capture, reporting, and prepare to manage incoming clients as new work is awarded and operational needs arise.
• Assist with business development activities as requested.

Who You are:

The PI Client Success Specialist is an excellent customer service representative and has the ability to support the Director and the PI team.

Our requirements for this role:

• Bachelor’s degree required with licensure in criminal justice, human services or business related field; Master’s Degree preferred.
• Minimum of two (2) years’ experience in Program Integrity or FWA contract or program work; supervisory experience preferred.
• Certified Professional Coder or Certified Fraud Examiner preferred.
• Proficiency in Microsoft Suite (Word, Excel, PowerPoint, Outlook etc.), web platforms, and SharePoint.
• Experience in Quality Management/Improvement and implementation of Corrective Action Plans preferred.
• Excellent communication skills, both written and oral.
• Experience writing professional reports and presenting to diverse audiences.
• Basic understanding of data management and statistics preferred.

Why Constellation Quality Health

We offer a competitive salary and benefits package and a flexible work environment.

Equal opportunity employer of protected veterans

Equal opportunity employer of individuals with disabilities

We do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, gender identity, national origin, medical condition, disability, veteran status, or any other basis protected by law.

Applicants and employees are protected from discrimination based on inquiring about, disclosing, or discussing compensation or the compensation of other applicants or employees.