The Claims Auditor will be responsible for the accurate review and auditing of claims that are adjudicated by the system and the Claims Examiners. The auditor will suggest process improvements to management and act as a resource of information to all staff. The Claims Auditor will identify overpayments and coordinate with the Claims Recovery Unit.

Responsibilities:

• Audit claims as it relates to the appropriate Federal and State regulations based on the member’s Line of Business.
• Read and interpret DOFRs as it relates to the claim in order to ensure that group is financially at risk for payment.
• Read and interpret provider contracts to ensure payment accuracy.
• Read and interpret Medi-Cal and Medicare Fee Schedules.
• Utilize auditing tools to identify and determine accuracy of claims payments (prospectively and retrospectively).
• Coordinate with internal departments for any issues relating to provider, fee schedule, eligibility, authorization, or system issues.
• Complete appropriate documentation for tracking/trending of data in order to identify system issues and remediation.
• Provide regular feedback to the Claims Management team concerning process improvement opportunities, or any training opportunities relative to adequacy of file investigation/ development in advance of the recovery effort.
• Coordinate with the Recovery Department for any identified overpayments.
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.
• Other duties as assigned.

Qualifications:

• HS Diploma or GED
• 3+ years of Claims Processing experience
• Must be knowledgeable of Medi-cal regulations
• Preferred knowledge of Medicare and Commercial rules and regulations
• Knowledge of medical terminology
• Must have an understanding to read and interpret DOFRs and Contracts.
• Managed Care concepts
• Must have strong organizational and mathematical skills.

Skills and Abilities:

• Intermediate to advanced word processing, spreadsheet, presentation, and internet skills.
• Expert-level working knowledge of complex billing and documentation regulations, with the ability to research additional topics when necessary.
• Strong analytical, detail-oriented skills with a firm understanding of healthcare operational processes and technology concepts.
• Ability to express complex issues in clear and concise written and verbal updates, reports, and recommendations.
• Ability to maintain the highest standards of confidentiality and to work with a high degree of integrity to perform objective and constructive audits.
• Strong investigative and project management skills.
• Highly motivated with great organizational skills and the ability to multitask, handling interruptions and achieving deadlines.
• Ability to perform services in a variety of work settings while maintaining a high degree of customer service.
• Demonstrates a results-oriented approach for delivering service in an accurate, complete, and timely fashion.
• Demonstrate success working both individually and with a team in a fast-paced, high volume, deadline oriented environment with emphasis on accuracy and timeliness.
• Excellent communication skills, both oral and written, in order to deal effectively with a variety of interpersonal relationships and situations.
• Ability to follow up on pending issues and meet deadlines.
• Ability to cultivate strong working relationships with personnel from various areas of responsibility within the organization and interact with employees, customers and vendors in a professional manner.
• Must be able to follow directions and perform independently according to departmental standards when no directions are given.
• Must be able to willingly accept responsibility and possess the desire to learn new tasks.

Job Type: Full-time

Pay: $30.00 - $35.00 per hour

Benefits:

• Dental insurance
• Flexible schedule
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Montebello, CA 90640: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Claims Processing: 3 years (Required)

Work Location: Hybrid remote in Montebello, CA 90640

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