Overview
The Insurance Audit Manager will oversee and manage the insurance billing, claims-audit, and compliance functions for the dental practice/group. They will develop audit policies/procedures, lead reviews of insurance claim submission and payment reconciliations, identify risks of overbilling / under-billing / coding inaccuracies, provide guidance to front-office, billing and treatment-coordination teams, and ensure the practice remains compliant with third-party payor/insurer requirements and regulatory standards.
Key Responsibilities
- Develop, implement, and maintain a risk-based audit program for insurance claims (both patient-benefit insurers and third-party payors) specific to dental procedures: coding accuracy, predeterminations, documentation supporting treatment, patient eligibility.
- Lead regular audits of submitted claims: review claim codes vs treatments performed, verify pre-authorizations, flag exceptions, identify patterns of denials or write-offs.
- Monitor accounts receivable and payer payment trends, identify anomaly or risk (e.g., unusually high denial rates, large write-offs, missing documentation).
- Work closely with billing/claims team, treatment coordinators, and clinical staff to ensure proper documentation, predeterminations, correct coding (e.g., per provincial dental fee guide or insurer schedule), and efficient claim submission.
- Provide training and support to clinic staff on insurance billing best-practices, claim submission, appeals, denials management, predetermination workflows, and audit-preparedness.
- Maintain and update standard operating procedures (SOPs) relating to insurance billing, audits, documentation requirements, appeals processes, and internal controls.
- Liaise with external insurers, benefit administrators and third-party payors to clarify claim issues, respond to audit queries, and implement improvements.
- Prepare and present audit-findings, key metrics (e.g., denial rate, days in AR, write-off ratio, correction-rate) to senior management/owners; recommend corrective action and monitor remediation.
- Ensure compliance with regulatory requirements, provincial dental associations, patient-privacy legislation, and insurer requirements.
- Manage, mentor and supervise any audit/claims-review staff, set goals and track performance.
- Potentially participate in selecting/implementing practice-management or billing software enhancements, analytics tools for claim monitoring.
- Maintain awareness of changes in dental insurance policy/benefit design, insurer guidelines, predetermination requirements, and adjust audit program as needed.
Qualifications & Skills
- Bachelor’s degree in business, health administration, accounting, or related – or equivalent relevant experience.
- Several years (e.g., 5-10) of experience in dental office billing/claims or insurance administration within dental or health-care setting.
- Strong knowledge of dental insurance processes, predeterminations, claim submission, denial/appeal processes, and dental coding/fee-guide familiarity.
- Audit, compliance or internal-controls experience is a strong asset.
- Excellent analytical skills: ability to review data, identify trends/anomalies, recommend improvements.
- Strong communication and training skills: able to work cross-functionally with clinical, administrative and financial staff.
- Detail-oriented with strong organizational and time-management ability.
- Experience supervising and developing staff.
- Proficiency with practice-management software, MS Excel/spreadsheets, audit/analytics tools preferred.
Working Conditions
- Full-time salaried position.
- Office-based in the dental clinic’s head office or main site; may include occasional visits to satellite clinic locations (if multi-site).
- Reports to Practice Owner/General Manager/Director of Operations (depending on size).
- May require flexible hours during audit-cycles, month-end reviews or when claims issues escalate.
Key Performance Indicators (KPIs)
- Reduction in insurance denial rate (percent of claims denied).
- Days in accounts receivable (AR) for insurance-claims.
- Ratio of write-offs due to claims issues / billing errors.
- Accuracy rate of claim submissions (audit-correction rate).
- Number of staff trained and compliance incidents identified and resolved.
- Documentation completeness (supporting treatment codes, predetermination, etc.).
- Audit-finding closure / remediation rate.
Salary commensurate with experience
Salary and benefits and positions based in NE Calgary
Relocation allowance and accommodation help for right candidate
Job Type: Full-time
Pay: $80,311.72-$157,844.47 per year
Work Location: In person
