Top Managed Care Executive jobs in Baltimore, MD

We are looking for a Managed Care Auditor to join our growing government-based healthcare practice. Please contact me for details.

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Managed Care Auditor wanted …

Established in January, 2005, our audit firm, based in Baltimore, MD is dedicated to health care compliance of government providers, health plans and contractors. Government health care compliance services represent a large portion of our firm’s clients. We audit some of the largest & most complex health care organizations in the country utilizing a team approach drawing on various areas and levels of expertise.

As a Managed Care Auditor on our Assurance Team, you will be involved with compliance audits, examinations, and agreed-upon procedure engagements. You will also apply your experience and knowledge of patient care and/or operational processes by making suggestions to improve client internal controls and operational procedures.

Position Summary: Managed Care Auditor

The Managed Care Auditor will participate in team webinar audits focusing on compliance reviews. Audit teams include Part C Organization Determinations, Appeals and Grievances (ODAG); Medicare-Medicaid Plan (MMP) Service Authorization Requests, Appeals, and Grievances (SARAG); Special Needs Plans Care Coordination (SNPCC); Medicare-Medicaid Plan Care Coordination (MMPCC); and Compliance Program Effectiveness (CPE). The position is responsible for reviewing policies and procedures, internal controls, and claims / medical records to determine a Plan Sponsor’s compliance with Medicare rules and regulations. All necessary training will be provided including working on various teams to gain direct experience on the process. Minimal to no travel required.

Desirable background:

• 5 years of Medicare Audit experience
• Familiarity with Compliance Program goals and objectives;
• Familiarity with Organization Determinations, Reconsiderations, Appeals and/or Grievance processes and regulations;
• Working knowledge of provider billing guidelines, payer reimbursement policies and related industry-based standards;
• Experience with medical necessity determinations applying clinical judgment, utilizing medical necessity criteria and screening tools based on nationally recognized tools;
• Direct experience in reviewing medical records;
• Working knowledge of DRG, ICD-9/10, CPT and HCPCS codes;
• Medical coding certification is a plus!
• Experience analyzing claims data is a plus!
• Prior auditing experience in either a provider or payer environment; and
• Proficiency with Word, Excel and other applications.

Job Type: Full-time

Pay: $90,000.00 - $100,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Education:

• Bachelor's (Required)

Experience:

• Auditing: 5 years (Preferred)
• Microsoft Excel: 5 years (Preferred)

Work Location: Hybrid remote in Nottingham, MD 21236