Auditor, Compliance

Regal Medical Group•Los Angeles, CA

2d•$30 - $32•Onsite

About The Position

The Claims Compliance Auditor is responsible for performing activities related to benefit analysis and system design, managing special projects, claim denials, and auto-adjudication applications as they apply to auditing and claims compliance. This includes oversight of all workflow, research, and documentation under limited supervision by the Claims management. The role identifies potential company risks and implements appropriate courses of action and develops strategies to reduce adjudication errors. The auditor analyzes all relevant information to track and trend special project outcomes to provide findings to appropriate management.

Requirements

5 years working knowledge of claims processing and system configuration, preferably EZCap or like systems in the healthcare system.
Strong ability to collaborate with management and other project managers to define business process issues, analyze operational efficiencies, implement creative solutions, and measure delivery results.
Should exhibit a disciplined, process and data-driven approach.
Knowledge of claims processing and regulatory agencies requirements.
Requires strong organizational, communication and written skills.
Must be able to function with minimal supervision and be able to prioritize all work.
Demonstrated ability to conduct and interpret qualitative and quantitative analysis and problem-solving skills.
Ability to work well with individuals in all levels of the organization; must be an effective team player.
Demonstrated ability to exercise initiative, independent judgment and be a self-starter.
Strong PC-based business software skills including MS Office suite (Access, Excel, PowerPoint, Word).

Responsibilities

Utilizes standardized processes, tools, methodologies, and presentation templates, progress/milestone reports, track audit issues.
Communicates effectively with all appropriate internal and external individuals, as well as maintain regular contact with the Claims and Finance management and other project sponsors to coordinate project activities as appropriate.
Prepares and presents regular project progress reports for Claims management and other project sponsors such as Finance management as it relates to claims compliance.
Works closely with other members of Finance and Claims management to plan project activities such as, but not limited to, Auto-adjudication, system pricing, training development based upon claims compliance.
Responsible for auditing denied claims.
Responsible for assisting with health plan and regulatory audit preparations; such as scheduling, compile/vet audit universe reports, any additional documents required and results.
Responsible for assisting in development and testing of auto-adjudication.
Ability to translate health benefit plan design, claims, health-related insurance products into systems configuration.
Provides technical support, training assistance, and expertise to Claims staff or other departments as determined through all phases of the project (e.g., Research, Outcomes, Provider notification of findings).
All other duties as directed by management.