Mount Carmel Health System

About Mount Carmel Health System


Job Category:

Quality, Risk Management and Compliance, Leadership


United States

Postal Code:


Approximate Salary:

Not Specified

Position Type:

Full Time

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Manager, Claims Audit - MediGold - Corporate Services Center

Mount Carmel Health System - Columbus, Ohio

Posted: 07/4/2018


OH1CH_70505_000 Mchp Audit

Expected Weekly Hours:



Day Shift

Position Purpose:

At Mount Carmel, we work to continuously inspire one another. Here, all are welcome. It is this culture of humility and compassion that sets Mount Carmel apart. We see the big picture and do the right thing. That means a dedication to the well-being our both our colleagues and the patients they serve.

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries in Ohio. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

The Manager, Claims Audit, manages the activities of the Claims Operations Department. He or she is accountable for operational leadership of provider billing practices, provider contract interpretation & operationalization, and coding & reimbursement practices based on government regulations. The position is expected to motivate staff to achieve the highest levels of customer service, quality and financial performance. The position optimizes staff performance through process redesign, policy/procedure recommendations, communications, and outcomes feedback.

Job Description Details:


  • Serves as the main point of contact and as the Claims subject matter expert (SME) for internal and external auditors.
  • Leads all activities intending to identify, research and analyze the department's technical support needs and to effectively implement new technologies when approved to improve operations, user efficiencies and consumer experiences.
  • Proactively responds to and resolves claims issues from provider and members.
  • Supervises the day to day activities of the Claims staff and BPO (vendor) operations.
  • Develops audit and claims related goals and quality standards that improve department metrics and to best meet performance measures aligned with the company's strategic goals.
  • Conducts audits, monitors daily performance of department and vendors and provides immediate feedback to colleagues and supervisor.
  • Acts as a liaison and interacts between Claims and other departments within MediGold.
  • Directs and manages staff performance in accordance with Human Resource policies and procedures & oversees and ensures the maintenance of and adherence to departmental policies and procedures implemented by MediGold.
  • Researches and operationalizes trending audit protocols based on CMS news releases and information.
  • Takes a proactive approach when issues are identified by presenting to upper management explanations for variation and potential solutions to resolve issues and actively participates in the decision making process.
  • Serves as primary trainer and preceptor for the Claims department through developing and directing ongoing training programs resulting in increases to staff competencies and effectiveness.
  • Functions as the first line resource for Claims colleagues.
  • Ensures that department colleagues have maintained annual education and credentials as required by their positions.
  • All other duties as assigned.


  • Education: Bachelor's Degree or equivalent combination of education and experience.
  • Licensure / Certification: CPC or equivalent certification preferred
  • Experience: Minimum five (5) years' experience in medical claims or relevant experience required
  • Knowledge of Medicare and Medicare Advantage
  • Ability to lead and manage a diverse staff in an intense work environment
  • Demonstrates leadership skills and ability to include a high degree of initiative
  • Demonstrated ability to understand and meet all technical, educational and operational needs of a Service Center.
  • Experience developing, executing, measuring and monitoring and continuous service performance improvement initiatives to targeted outcomes.
  • Must be proficient with all Microsoft Office automation software and knowledge of the claims platform and ancillary applications.
  • Demonstrates high tolerance for ambiguity and change while providing leadership to department staff to adapt effectively to meet changing environment

Discovering opportunities, support and excellence – all while making a real difference in patients’ lives – begins at Mount Carmel. Find a new beginning and advance your career with us.

Mount Carmel and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, sexual orientation or physical ability.



Trinity Health's Commitment to Diversity and Inclusion

Trinity Health employs more than 120,000 colleagues at dozens of hospitals and hundreds of health centers in 21 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.

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