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.
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About Your Team
Are you looking to work with a high performing, fast growing and dynamic Claims team? Altais and our subsidiaries, form one of the most recognized medical groups in California. We are 3,000+ physicians, working in over 40 cities in California, caring for more than 350,000 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
This position is responsible and accountable for the supervision and performance management of Claims Appeals and Recovery staff as well as overseeing day to day operations of the Claims Appeals and Recovery team. Manage internal claims appeals and recovery processes and workflows to ensure consistent qualitative compliance with BTP policies/contracts and State, Federal and Health Plan regulatory requirements. Develops and implements work plans with actionable components and measurable outcomes using continuous improvement processes. Proactively monitors key performance indicators and displays that information through dashboards and metrics and makes real time adjustments to ensure that projects stay on track. Manage provider and member appeal policies and workflows to include compliance with internal service level agreements and State, Federal and Health Plan regulatory timeliness/qualitative requirements. Responsible for ensuring staff compliance with Brown and Toland recovery policies.
You Will Focus On
- Manage and update claims audit and PDR/appeals/health plan cap deduct policies, workflows and processes to ensure compliance with Claims department and State, Federal and Health Plan quality standards. Provide analysis of claims quality adjudication results and identify training opportunities for Claims Reps.
- Responsible for ensuring accurate reporting and timely submission of quarterly PDR timeliness reports.
- Responsible for the preparation, coordination, and facilitation of external party PDR and adjustment audits. Responsible for development of any corrective action plans (CAPs) that result from PDR and adjustment audit findings.
- Responsible for monitoring progress and application of documented CAPs.
- Responsible for developing and administering measurement tools to effectively monitor recovery activities. Serve as the primary point of contact to answer questions related to various recovery issues and resolve non-routine, complex recovery issues for department staff as well as other internal customers.
- Work with the Brown and Toland departments and BPO on implementing controls to minimize claims overpayments and identify physician education opportunities with Network Management.
- Work closely with BPO and other Brown and Toland departments (e.g., Operational Integrity team) to communicate findings of recovery audits and to facilitate accurate adjudication of claims.
- Collaborates and effectively interfaces with all departments and employee levels to ensure optimal results and productive working relationships.
The Skills, Experience & Education You Bring
- Seven (7) years prior claims processing experience in an IPA or HMO related setting, with a minimum two (2) years in a lead or supervisory capacity.
- Experience with Epic/Tapestry system preferred.
- Seven (7) years knowledge of and working experience with ICD-10, CPT and HCPC coding systems.
- Working understanding of basic computer operations and medical insurance rules/regulations
- Thorough knowledge of medical terminology, claim processing procedures/systems, auditing, and a thorough understanding of claim protocols, industry standards and CMS regulations as it relates to claims payment and compliance. Advanced knowledge of claims processing systems architecture, which will facilitate troubleshooting of claims transaction related issues.
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.
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.
Altais is a leading network of independent doctors focused on delivering personalized and high-quality health care in over 40 cities in California. Its network of more than 3,000 physicians, serving more than 355,000 HMO, ACO and PPO patients, is dedicated to improving care and reducing costs through innovative care management and care coordination programs, use of health care technology, and population health management strategies. For more than 30 years, Altais and its family of companies has proudly collaborated with leading hospitals and health plan providers to provide high quality care in California
Please note that Brown & Toland Physicians is a wholly owned subsidiary of Altais Clinical Services, a division of Altais. Other subsidiaries in the Altais family of companies include Altais Medical Group Riverside and Family Care Specialists Medical Group.
If you would like to search for other open positions within the Altais family of companies, please view the links below:
· Altais Medical Group Riverside (https://altais.com/altais-medical-group-riverside/employment-opportunities/)