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　　Come join our Peak Health team at WVU Medicine as an Claims Audit Specialist (IAC), contributing to the foundation for an innovative, new Medicare Advantage health plan. This position will report to the Director of Claims Operations, playing a unique and important role in our mission to change healthcare for the better.Experience in the healthcare industry, medical and pharmacy claims monitoring, critical thinking, and attention to detail will help this role build an effective and efficient audit and oversight function. The Claims Audit Specialist will work with Peak leadership to create, implement, and oversee the medical and pharmacy claims audit and reporting process, collaborating with Compliance as needed.This role will be instrumental in medical and pharmacy claims implementation from an audit perspective. You will work with management and peers on the Peak team to build the audit process and perimeters, along with a formal reporting structure. You will evaluate processing quality, while developing coaching and training to address issues.

　　MINIMUM QUALIFICATIONS:EDUCATION, CERTIFICATION, AND/OR LICENSURE:1. Bachelor's Degree, or greater in related Healthcare field.EXPERIENCE:1. Two (2) years of experience working with audits in a health care capacity.2. Five (5) years of medical and pharmacy claims and adjustment processing experience.3. One (1) year of provider/member file maintenance experience.

　　PREFERRED QUALIFICATIONS:EDUCATION, CERTIFICATION, AND/OR LICENSURE:1. Master's Degree, or equivalent experience, in related healthcare field.EXPERIENCE:1. Seven (7) or more years in a medical and pharmacy claims processing and audit environment.2. Three (3) or more years with audit or quality control oversight.3. Three (3) or more years of mentoring and/or training experience.4. Two (2) or more years of formal audit response experience. (CMS, SOX, etc.)5. Two (2) or more years of familiarity with member and provider contract structure and file maintenance.6. At least one (1) or more years of quality report creation and implementation experience.

　　CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

　　Creates and conducts regularly scheduled audits of claims team processes and outputs.Creates and conducts regularly scheduled audits of claims team adherence to production metrics.Assesses claims staff production and quality within department standards.4.... For full info follow application link.Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.

　　The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)