Due to Covid-19 we are working 100% remotely; this includes the hiring process. When it is safe to do so, we will return to a hybrid of onsite and remote work for some positions. This position can be almost entirely remote, but there are times when it may be beneficial to gather with other Arcadians or customers in person - so occasional travel may be required or encouraged.
Why This Role Is Important To Arcadia
As a Compliance Auditor, you will ensure the accuracy of the required reporting and procedural and financial claims processing requirements set forth by the client and Health Plan contract requirements for the Value Based Care lines of business. This position is responsible for regulatory and contract compliance in the managed care - Commercial and Medicare Advantage environment.
What Success Looks Like
In 3 months- Intermediate knowledge on the Claims processes within claims processing software.- Novice understanding of Encounter Submission audits and processes.- Novice to Advanced knowledge of all BCBS Medicare Advantage report requirements and the required data to be submitted- Novice understanding of authorization requirements.- Consistently performs daily, weekly, monthly audits.
In 6 months- Create impact reports for errors found in internal and external audits.- Processing refunds independently.- Report audit findings to department managers for coaching, mentoring and tracking of audit percentages.- Consistently and accurately assist in encounter submission audits and Medicare Advantage reporting requirements.
In 12 months- Intermediate understanding of UM Challenges and Reinsurance audits and appeals.- Novice knowledge of external payor audits.- Identify the need for higher level system enhancements as report and claim requirements evolve and/or change.- Bring forward new ideas, audits and processes.
What You'll Bring

• Minimum 3 years of experience in the healthcare or managed care industry, including claims/reimbursement experience, professional analytics-related experience and experience working on/managing major projects.
• Minimum 1-3 years of Medicare Advantage HMO experience in the healthcare or managed care industry, including claims/reimbursement experience, auditing, professional analytics-related experience and experience working on/managing major projects.
• 1-3 years auditing experience in the healthcare industry.
• CPT and ICD coding knowledge.
• Knowledge of Medicare requirements and APC Pricing knowledge.
• Advanced to expert proficiency in the Microsoft Office products, especially Microsoft Word, Microsoft Excel & Microsoft Access.
• Able to problem solve, exercise initiative and make medium to high level decisions.
• Thorough understanding of current federal, state and local healthcare compliance requirements.
• Ability to meet deadlines and prioritize tasks; collect, correlate and analyze data.
• Ability to work independently with minimal supervision and as part of a team.
• Must be organized, self-motivated, detail-oriented, disciplined, professional, and a team player.
• Effective written and oral communication.

Would Love For You To Have

• Bachelor's degree in healthcare informatics, business administration, or related field, or equivalent in experience and education.
• Medicare Advantage HMO experience in the healthcare or managed care industry, including claims/reimbursement experience, auditing, ODAG/Part C Reporting, professional analytics-related experience and experience working on/managing major projects.
• Certified Professional Coder strongly recommended or willing to obtain within 6 months of hire.
• Experience and knowledge with Medicare Advantage strongly encouraged.
• Prior claims processing experience within Eldorado HealthPac Claims Adjudication System is a plus.
• Claim coding experience, coding edits experience and APC Pricing knowledge.
• CPT and ICD coding knowledge.

What You'll Get

• Learn the life of a Contract Management firm with Independent Physician Associations across Illinois.
• Encouragement to bring ideas to the table.
• Be an integral part of a desired team within Arcadia's Value Based Services.
• Expand your claims processing knowledge to the "behind the scenes" aspect.
• Opportunity to be part of a team creating automated processes to drastically improve healthcare.
• Extraordinary and flexible work environment and culture.
• Competitive compensation.
• Amazing benefits package including flexible time off.
• Receive cash compensation with health, dental, and other benefits.

About Arcadia
Arcadia.io helps innovative healthcare systems and health plans around the country transform healthcare to reduce cost while improving patient health. We do this by aggregating massive amounts of clinical and claims data, applying algorithms to identify opportunities to provide better patient care, and making those opportunities actionable by physicians at the point of care in near-real time. We are passionate about helping our customers drive meaningful outcomes. We are growing fast and have emerged as the market leader in the highly competitive population health management software and value-based care services markets, and we have been recognized by industry analysts KLAS, IDC, Forrester and Chilmark for our leadership. For a better sense of our brand and products, please explore our website , our online resources , and our interactive Data Gallery .
This position is responsible for following all Security policies and procedures in order to protect all PHI under Arcadia's custodianship as well as Arcadia Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.