Financial Compliance Auditor III Claims

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan, serving more than 2 million members. Our mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

About the role

The Financial Compliance Auditor III Claims is responsible for audits of claims processed by Delegated Participating Physician Groups (PPGs), hospitals and health plans contracted with L.A. Care and various tasks within the Financial Compliance Unit. This position works closely with management on identification and resolution of issues in a timely and efficient manner. The Auditor III is responsible for all aspects of assigned claim audits, including audit testing and completion of the audit report, and covers complex areas of the Medi-Cal, Medicare, Covered California, and PASC-SEIU benefit and process. The role reviews claims processing data to ensure delegated entities comply with federal and state regulations and contractual agreements, focusing on contractual and regulatory compliance with timeliness and appropriateness standards. This position acts as a Subject Matter Expert, serves as a resource and mentor for other staff, and performs other ongoing tasks as assigned by management.

Responsibilities

• Performs auditing procedures under minimal supervision during audits of PPGs, hospitals, and health plans.
• Conducts sub-delegation claims oversight audits of PPGs, capitated hospitals, and Plan Partners, including all claims processing sub-contracting functions of the delegates.
• Provides timely and accurate reports detailing whether PPGs, hospitals, and health plans meet regulatory and contractual requirements, presenting reports to supervisors within one week of the audit date.
• Reports any findings or issues that affect audit results.
• Prepares documentation needed prior to onsite claim audits in a timely manner.
• Performs ongoing tasks as assigned, such as compiling the Monthly Timeliness Report (MTR) and audit reports of Plan Partner oversight of their Independent Practice Association (IPA) network on a quarterly and annual basis.
• Applies subject expertise in evaluating business operations and processes, identifying areas where technical solutions would improve business performance.
• Consults across business operations, providing mentorship and contributing specialized knowledge.
• Ensures facts and details are correct so that project/program deliverables meet the needs of the department, organization, and legislative policies, standards, and best practices.
• Provides training, recommends process improvements, and mentors junior-level staff and department interns as needed.
• Performs other duties as assigned.

Requirements

• Bachelor’s Degree in Finance, Accounting, or a related field. In lieu of a degree, equivalent education and/or experience may be considered.
• At least 4 years of experience performing claims audits or claims processing related to Medi-Cal, Medicare, and/or other managed care product lines similar to L.A. Care’s L.A. Care Covered and PASC-SEIU programs.

Skills

• Self-motivated and detail-oriented.
• Able to prioritize assignments, multitask, and work as part of a team.
• Excellent verbal and written communication skills.
• Ability to interface professionally with both internal and external customers at all levels of the organization.
• Proficient in Microsoft Excel, Word, and data analysis.
• Knowledge and understanding of legislation and regulatory bodies affecting healthcare practices.
• Knowledge of the insurance industry’s trends, directions, major issues, and regulatory considerations.
• Knowledge of health insurance products, market segments, and marketplaces.

Licenses/Certifications

Preferred certifications or licenses may be specified, though none are explicitly required for this role.

Pay

Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.)

Benefits

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental, and Vision coverage
• Wellness Program
• Volunteer Time Off (VTO)

Physical Requirements

Light physical activity may be required.