Senior Claims Auditor

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

About the Role

We are currently seeking a highly motivated Senior Claims Auditor. This role will report to the Director - Claims and enable us to continue to scale in the healthcare industry.

Responsibilities

• Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits
• Review samples provided by clerical staff and ensure claims payments are accurate and all documentation required by the health plan auditor is 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, address the root cause appropriately, and 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 Overpayment requests
• Accurately document underpayments and overpayments 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 & 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 & resolution
• Identify training needs/gaps for the team and ensure timely and effective training is imparted to all team members

Qualifications

• A High School Diploma or Equivalent
• At least 2 years of experience as a Medical Claims Auditor or 7 years previous experience examining Claims
• 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
• Detailed 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.
• Detailed knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
• Working knowledge of NCQA, DHS, and HCFA standards
• Knowledge of medical terminology combined with detailed knowledge and experience with CPT, HCPCS, DRG, REV, OPS, ASC, ICD10, CRVS, RBRVS, CMS, ICE for Health Plan, DMHC, and DHS fee schedules and CMS Medicare regulatory agencies, COB, and Third-Party Liability recovery
• Ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC Regulations
• Ability to effectively present information and respond to questions from managers, employees, customers
• Advanced reasoning and problem-solving abilities and planning skills
• Ability to multi-task, prioritize, and work in a fast-paced environment under minimal supervision
• Proficient in Excel, including the ability to create and revise Excel spreadsheets to provide accurate and clear reports
• Strong independent decision-making, influencing, and analytical skills
• Extensive knowledge of claims processing guidelines including perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines

Bachelor’s degree preferred.

Schedule

Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis.

Pay

The target pay range for this role is between $70,308.00 - $80,000.00 per year. Actual compensation will be determined based on geographic location, experience, and other job-related factors.