Overview
This role involves working as a Claims Auditor responsible for ensuring the accuracy of claims processing in accordance with department policies, CMS, and DMHC regulations. The position supports quality health care delivery by auditing claims for compliance and accuracy.
Responsibilities
- Conduct detailed audits to ensure compliance with State, Federal, and Health Plan regulatory requirements
- Perform pre- and post-payment audits on adjudicated claims following organizational policies, procedures, and payment methodologies
- Document audit findings and present errors to Claims Operations for correction, root cause analysis, and resolution
- Analyze errors and inconsistencies and prepare recommendations for management
- Suggest process improvements to management
- Monitor appeals from providers, members, and health plans to ensure accurate and timely processing
- Oversee daily auditing of processed claims and correspondence for accuracy
- Manage multiple projects and ensure deadlines are met
Requirements
Education
- High School Diploma or GED required
- Bachelor's Degree in healthcare or related field preferred
Experience
- Minimum 4 years of professional and facility claims processing experience for Medicare and Commercial products
- Familiarity with provider dispute resolution preferred
- Preferred 5 years of senior, lead, or claim audit experience in a medical claims setting
Location
Southern California