Senior Claims Auditor

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Location: 600 City Parkway West 10th Floor, Orange, CA 92868

Compensation: $70,000 - $83,000 / year

Department: Ops – Claims Ops

Duties: 50% Audit & Oversite, 35% Audit Documentation/Reconciliation, 15% Collaboration.

Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits. Review samples provider by clerical staff and ensure claims payments are accurate and all documentation required by the health plan auditor are present at the time of audit. Requires the ability to communicate and analyze claims processing methodologies according to CMS and DMHC guidelines. Respond to preliminary results by the due dates.

Respond to the corrective action plan timely and address the root cause appropriately as well as remediate the deficiency. Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows. Handle complex and urgent audit projects from external providers and internal departments. Assist the Recovery Specialist in corresponding with external providers regarding claims over payment requests.

Audit Documentation/Reconciliation:
Accurately document the underpayments and over payments into the audit database. Assist management with analyzing claim error trends. Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer.

Collaboration:

Build and maintain productive and collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/Finance, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification and resolution. Identify training needs or gaps for the team and ensure timely and effective training is imparted to all team members. Other duties are assigned.

• Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits
• Review samples from providers by clerical staff and ensure claims payments are accurate and all documentation required by the health plan auditor are present at the time of audit
• Communicate and analyze claims processing methodologies according to CMS and DMHC guidelines
• Respond to preliminary results by the due dates
• Respond to the corrective action plan timely and address the root cause appropriately as well as remediate the deficiency
• Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows
• Handle complex and urgent audit projects from external providers and internal departments
• Assist the Recovery Specialist in corresponding with external providers regarding claims over payment requests

• Accurately document the underpayments and over payments into the audit database
• Assist management with analyzing claim error trends
• Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer

• Build and maintain productive and collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/Finance, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification and resolution
• Identify training needs or gaps for the team and ensure timely and effective training is imparted to all team members
• Other duties are assigned

• Solid understanding of the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) rules and regulations governing claims adjudication practices and procedures
• Detail knowledge and understanding of industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi‑Cal fee schedule, All Patient Refined Diagnosis Related Groups (AP‑DRG), Ambulatory Payment Classifications (APC), etc.
• Detail knowledge of Medi‑Cal, Medicare, and Medicaid program guidelines
• Possess working…