Auditor; GARS

Overview

Auditor (GARS) – Cal Optima

Join Us in this Amazing Opportunity

The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, review and apply today and help us build healthier communities for all.

We are hoping you will join us as a Auditor (GARS) and help shape the future of healthcare where you ll be an integral part of our Grievance & Appeals team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders.

This position has been approved to be Full Telework
.

If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

The Auditor for Grievance and Resolution Services (GARS) will be responsible for auditing provider disputes, grievance and appeal activities performed within the GARS department to ensure compliance with Cal Optima Health policies and federal and state regulatory requirements. You will support compliance across Medicare, Medi-Cal and Covered California lines of business. You will review quality assurance results, identify trends, evaluate operational risks and provide actionable recommendations to leadership.

Additionally, you will audit letters for all lines of business, which involves specialized knowledge and background regarding grievance, appeals, provider dispute resolution, authorization rules, claim processing, division of financial responsibility and regulatory guidelines relevant to provider disputes, grievance and appeals. You will work independently, exercise judgment and support enterprise audit readiness efforts. Together, we are building a stronger, more equitable health system.

• 95% - Auditing Functions
• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Conducts risk-based and targeted audits of grievances, appeals and provider disputes using Cal Optima Health's approved tools consistent with all regulatory, contractual and accrediting standards and requirements.
• Assists with the development, revision and maintenance of all audit tools and score cards as necessary, to comply with state and federal regulatory requirements and internal department processes.
• Serves as a subject matter expert in the audit and review of provider disputes, appeals and grievances.
• Evaluates case classification accuracy, regulatory timeliness, documentation completeness and correct case closures.
• Compiles, summarizes and presents audit findings to department leadership, including recommendations for improvement.
• Develops and maintains reporting and trend analyses for leadership.
• Evaluates and audits case files to ensure cases were resolved within required regulatory time frames and determines whether the correct case classification was applied appropriately in compliance with Cal Optima Health policies, procedures, and regulatory requirements.
• Reviews grievance and appeal resolution letters to ensure member and provider concerns are accurately identified, addressed and resolved. Verifies language is appropriate for each line of business, and that complaint categories and codes are correctly applied.
• Audits appeals and provider dispute overturn decisions and validates that they are effectuated correctly, promptly and in accordance with all requirements.
• Collaborates with Training Program Coordinators and management to identify opportunities for training, system enhancements or workflow improvements related to grievances, appeals and provider disputes.
• Assists in the development, review and implementation of departmental policies and procedures.
• 5% - Completes other projects and duties as assigned.

• Bachelor s degree PLUS 2 years of experience in auditing, claims, grievances and appeals or provider disputes in a health care setting required, preferably in a managed care environment; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
• HMO, Medicare, Medi-Cal/Medicaid, Covered California and health services experience required.

• 3 years of experience auditing or reviewing provider dispute resolutions, appeals and grievances within a managed care or health plan environment.
• Experience with both Medicare and Medi-Cal billing and…