Auditor - Provider Recovery

Inland Empire Health Plan•Rancho Cucamonga, CA

1d•Hybrid

About The Position

Overview What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Under the direction of the Provider Claims Resolution & Recovery Supervisor, the Provider Recovery Auditor is responsible for the audit and recovery of claims overpayments including COB and third-party liability. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account – Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities Initiate and expand recovery opportunities through provided audit results, Provider calls, Third Party Liability and CCS eligible services. Audit payment errors that result in Provider refund checks to properly apply funds and determine the root cause. Communicate with and answer Provider inquiries and/or Provider Disputes regarding the reason for the refund request based upon claims processing guidelines, contractual agreements involving the use of established payment methodologies, Division of Financial Responsibility, and regulatory guidelines. Promote teamwork and maintain effective working relationships with others throughout the organization. Perform any other duties as required to ensure Health Plan operations and department business needs are successful. Start your journey towards a thriving future with IEHP and apply TODAY ! Work Model Location This position is on a hybrid work schedule. (Monday & Friday - remote, Tuesday – Thursday onsite in Rancho Cucamonga, CA.)

Requirements

Minimum of four (4) years of claims processing experience including Medicare and Medi-Cal
Two (2) years of experience auditing claims in a managed care environment including contract and financial DOFR interpretation
Experience with MS Office applications
High School Diploma or GED required
Knowledge of Medi-Cal and CMS guidelines for claim payments
Strong analytical and problem-solving skills
Must be able to review cause and impact of problems and recommend realistic solutions both in writing and in meetings
Proficient in Microsoft Office, including being able to manipulate large data sets in Excel files
Excellent oral and written communication skills
Ability to build successful relationships across the organization

Nice To Haves

Bachelor’s degree from an accredited institution preferred

Responsibilities

Initiate and expand recovery opportunities through provided audit results, Provider calls, Third Party Liability and CCS eligible services.
Audit payment errors that result in Provider refund checks to properly apply funds and determine the root cause.
Communicate with and answer Provider inquiries and/or Provider Disputes regarding the reason for the refund request based upon claims processing guidelines, contractual agreements involving the use of established payment methodologies, Division of Financial Responsibility, and regulatory guidelines.
Promote teamwork and maintain effective working relationships with others throughout the organization.
Perform any other duties as required to ensure Health Plan operations and department business needs are successful.