Role Description This is more than a job! It’s an opportunity to lead claims processes within a mission-driven healthcare organization. In this role, you will maintain integrity and accuracy of the claims processing system across all PACE programs through claims audits and implementation of corrective actions. - Conduct reviews of claims processes against policy provisions and governing regulations to ensure compliance. - Conduct claims audits including standard audits and focused audits, to ensure accuracy and integrity of the claims processing system, working with PACE System Administrator on necessary system updates. - Ensure that claims are processed in compliance with agency and department policies and procedures, contractual agreements, and governing federal and state regulations. - Respond accurately, timely and professionally to all external and internal communications regarding claims audits, ensuring clarity and accuracy in all interactions. - Review and work weekly/monthly claims data reports from the claims processing system and maintain productivity goals set forth. - Review and approve weekly Precheck Registers for all PACE Organizations. - Ensure all claims appeals are worked timely across all PACE Organizations relevant to governing regulations and contract obligations. - Assist claims staff and PACE Organization staff in reviewing situations that may warrant focused claims audits. - Review claims for proper billing and processing, including timely submission, compliant coding, required authorizations, and accurate pricing and payment. - Assist staff on questions and issues related to pricing of claims. - Maintain accurate and detailed records of all claims audits, including documentation of actions taken, communications with internal staff, and corrective actions implemented. - Prepare and submit regular reports on claims processing accuracy and trends to the Claims Manager, Director of Health Plan Operations, VP PACE Business Operations, and other relevant stakeholders. - Maintain knowledge of PACE, CMS, and state Medicaid policies and claims guidelines. - Develop and implement claims auditing policies and procedures, contributing to the overall effectiveness and accuracy of the claims processing team. - Communicate to and prepare reports for the Claims Manager, Director of Health Plan Operations, VP PACE Business Operations, and PACE Executive Directors. - Support various projects from across the PACE Organizations and community-based program enterprise. - Assist with other duties and projects as assigned. Qualifications - Education: High School Diploma required; Associate’s degree or higher preferred. - Experience: 3+ years of experience with medical billing and coding/claims processing or auditing. - Strong communication and organizational skills. - Ability to analyze, problem-solve, and collaborate effectively. Requirements - Remote role. - Schedule: M-F 8:00 AM-5:00 PM. - Pay Range: $56,000-$65,000. Benefits - Comprehensive Medical, Dental & Vision Insurance. - 403(b) Retirement Plan with Discretionary Employer Contribution. - Generous Paid Time Off (Vacation, Holidays & Sick Leave). - Life Insurance & Short-Term Disability Coverage. - Employee Assistance Program for personal and professional support. - Wellness Incentives (up to $350 annually). - Early Pay Access (up to 50% up to $1000 of earned wages). - Career Development Opportunities. Company Description Volunteers of America National Services (VOANS) is a mission-driven organization dedicated to delivering high-quality healthcare, housing, and supportive services to those in need across the country. We serve seniors, veterans, individuals with disabilities, and families through innovative programs that promote dignity, independence, and well-being. With a strong commitment to compassion, integrity, and service, VOANS operates across multiple healthcare and housing settings nationwide. Our teams are united by a shared purpose, to strengthen communities and make a meaningful difference in the lives of those we serve every day.

• The Pharmacy Network Auditor is responsible for the maintenance and growth of the Pharmacy Network Audit program and processes at RxSense • Evaluates, reports and monitors all aspects pertaining to Pharmacy Network Auditing services • Serves as a subject matter expert regarding standard monitoring measures, auditing procedures, and best practices • Assesses risks suggested by audit vendor, performs appropriate audit procedures, and collaborates with pharmacy management for efficient issue resolution • Drafts and communicates audit findings to internal stakeholders; provides Quarterly Network Audit Performance Reports to leadership • Screens and summarizes authorized vendor audit results • Reviews results to identify fraudulent, erroneous, or abusive billing activity • Analyzes claims data for potential investigational FWA breaches of network pharmacies • Maintains audit documentation, and prepares statistical data for review and action • Develops and updates Standard Operating Procedures for audit and FWA Programs • Collaborates with key stakeholders to support pharmacy network initiatives.

Title: Professional Coding Auditor & Educator Location: Silver Spring United States Job Description: Location Silver Spring, Maryland, 20910 Category Finance & Revenue Management Job Id 00677755 Holy Cross Health - Employment Type: Full time Shift: Day Shift Description: Employment Type: Full-Time Shift: Days (SUMMARY) Position Highlights: - Competitive pay - Additional Benefits: tuition reimbursement, free parking, employee discounts - Quality of Life: Flexible work schedules - Advancement:  professional growth within the organization - Location: Holy Cross Health has two hospitals and four healthcare centers all a short driving distance from Washington DC and Baltimore, MD.  Description: - Monday-Friday The Professional Coding Auditor Educator performs medical record audits including but not limited to analysis of medical record documentation, validation of primary and secondary diagnoses and procedures; and ensuring proper assignment of diagnosis and procedure codes using coding guidelines established by the Centers for Medicare and Medicaid Services (CMS).  Responsibilities: - Monitors accuracy of centralized coders’ charge capture and coding with proper ICD-10, CPTs, as well as proper modifiers, adhering to local ministry and Trinity practices and policies. - Partners with leadership to improve HCC, high risk scoring, with provider and coder education. - Conducts ongoing reviews of patient medical record documentation and procedural and diagnosis coding by each practitioner. - Responsible for practitioner education in areas related to coding, documentation, and compliance. - Works closely with leadership and the department to establish and modify the charge description master (CDM) methodology and pricing models to ensure accuracy and regulatory compliance. - Reports to the Manager, Provider Revenue Operations What you will need: - High school diploma or equivalent combination of education and experience - Certified Professional Coder or Registered Health Information Technician accreditation required. - Minimum of 2-5 years of professional coding experience with comprehensive knowledge of ICD-10, CPT, and HCPCs modifiers.  Knowledge of Medicare, Medicaid, and other third-party billing rules and regulations. - 3-6 years of professional coding experience; ability to code from operative reports; prior auditing experience.( Preferred) - Effective verbal, written, and interpersonal communication skills with the ability to comfortably interact with diverse populations. - Ability to work collaboratively in a team-oriented environment with a strong customer-service orientation. - Ability to handle patient and organizational information in a confidential manner. - Ability to demonstrate competency with a standard desktop and Windows-based computer system, including a basic understanding of email, e-learning, intranet and computer navigation.  Ability to use other software as required to perform the essential functions of the job. - Demonstrated dependability and regular attendance. - Solid understanding of ICD-10 and CPT coding and medical terminology, with knowledge of Medicare, Medicaid, Health Maintenance Organization and commercial insurance plans. - Ability to exercise independent judgment as appropriate within standard practices and procedures. Pay rate: $ 28.00 – $43.40 Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location. About us: Holy Cross Health is a Catholic, not-for-profit health system that serves more than 240,000 individuals each year from Maryland's two largest counties — Montgomery and Prince George's counties. Holy Cross Health earns numerous national awards, clinical designations and accreditations across a wide range of specialties for providing innovative, high-quality health care services. We were named one of America’s 100 Best Hospitals for 2021. Holy Cross Health is an Equal Employment Opportunity (EEO) employer.  Qualified applicants are considered for employment without regard to Minority/Females/disabled/Veteran (M/F/D/V) status Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

• Perform certification audits in any capacity in conformance with the SGS Global/Local procedures, sector specific schemes/standards. • Ensure that such duties are performed in an efficient and commercially expedient way. • Collaborate with teams of Auditors during the auditing activities. • Assist in the training of other Auditors and Senior Auditors during planned audits or during other training functions. • Actively participates in witness audits by SGS or accreditation bodies. • Undertake any other activities as directed by the Manager, Certification Audit or Manager, Technical Accreditation.