Evolent Health Manager, Claim Audit & Quality Assurance in Chicago, Illinois

It’s Time For A Change…

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely—70.3% in year-over-year revenue growth in 2017. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016 and 2017, and one of the “50 Great Places to Work” in 2017 by Washingtonian, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

What You’ll Be Doing:

We are looking for bright and energetic individual to be a Manager, Claim Audit & Quality Assurance. The Manager, Claim Audit & Quality Assurance is responsible for managing all functions related to claim and configuration Audits ensuring that audits are executed in a timely and accurate manner. This includes generating monthly audit reports submitted to the internal stakeholders and the clients, working closely with the department heads of Enrollment, Billing, Claims, Configuration, Customer Service and Performance Improvement to share results of standard audits and ad hoc or focused audits process improvement, providing training and continuing education to staff as well as coaching and mentoring. The Manager, Claim Audit & Quality Assurance will be responsible for ensuring platform upgrade testing is complete, reviewing SharePoint and Jira tickets, responding to emails in a timely manner and providing feedback to the director. Direct reports may include supervisors, team leads and staff. Specific job duties may include, but are not limited to the supervision or performance of the following:

  • Ensure claims are adjudicated in compliance with provider contract parameters, member demographic information, and service level requirements through random and targeted claim reviews.

  • Conducts Audit-the-Auditor claim audits for Procedural and Financial accuracy.

  • Provide monthly/quarterly/yearly feedback used for client report cards and company Key Performance Indicators (KPI).

  • Participate in documenting and prioritizing potential solutions to issues & fallout for system issues.

  • Establish and implement interim workaround solutions as needed and communicate to all impacted users.

  • Assist in establishing, updating, and communicating new and existing policy and procedures.

  • Facilitate discussions and solutions with matrix partners and act as a subject matter expert.

  • Accountable for analyzing and measuring results of implemented policies, changes and system modifications.

  • Effectively monitor and handle multiple tasks.

  • Monitor staff time and attendance.

  • Perform quarterly and yearly reviews.

  • Effectively communicate across all levels of management and management personnel.

  • Ability to meet assigned deadline and work under minimal supervision and with all levels of staff and management.

  • Assist with internal and external audits.

  • Maintain required productivity standards (Workflow/SharePoint/Email/Jira).

  • Other duties as assigned.

The Experience You’ll Need (Required):

  • Extensive experience in health insurance claims processing with a minimum of 3 to 5 years management experience.

  • In-depth knowledge of medical billing and coding

  • Knowledge of health insurance, HMO and managed care principles

  • Strong knowledgebase of Medicaid, Florida Medicaid preferred

  • Strong leadership and management skills

  • Define and manage staffing needs including recruitment

  • Critical thinking skills to build efficiencies

  • Create and manage productivity reports

  • Create and maintain policy and procedures

  • Manage and execute projects

  • Excellent interpersonal, oral and written communication skills

  • Strong attention to detail and organization

  • Able to work independently; strong analytic skills

  • Strong computer skills

Finishing Touches (Preferred):

  • Associate or Bachelor’s degree preferred.

  • HMO Claims or managed care environment preferred.

  • Certified Biller and or Coder-preferred

Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.