Claims Quality Auditor II

L.A. Care Health Plan•Los Angeles, CA

6d•$67,186 - $107,498

About The Position

The Claims Quality Auditor II works closely with the Claims Quality Auditing Manager to ensure claims are processed in accordance with regulatory guidelines, Medi-Cal guidelines, and contractual agreements. The position maintains current knowledge of healthcare trends and issues, national and statewide standards and regulations, company policies and procedures, and the legal implications of federal and state regulatory guidelines related to claims. It serves as a liaison between partnering departments, including Payment Integrity and Claims Compliance, and researches complex claims problems. The role audits high-dollar claims, Provider Disputes, and Adjustments, and works with the Claims Operations Supervisor to develop procedures that support departmental goals and continuously improve work quality. It reviews payable and post-payment claims, conducts random reviews of claims audited by Quality Control Examiners to assess whether they meet the 98.00% quality score, and maintains current auditing competencies. The position also reviews high-dollar claims of $125,000 and stays current on First Pass, Provider Dispute Resolution (PDR), and Adjustments regulatory guidelines, including turnaround time frames across all lines of business.

Requirements

At least 4 years of claims processing experience in a Health Plan environment.
At least 3 years of experience as a claims auditor or analyst.
Prior experience working with Provider Dispute Resolution (PDR), third-party liability, and coordination of benefits claims.
Solid understanding of complex contractual documents and recent experience interpreting Health Plan benefit documents.
Good understanding of regulatory requirements pertaining to Medi-Cal and Medicare claims.
Excellent written and verbal communication skills.
Associate's degree; equivalent education and/or experience may be considered in lieu of a degree.

Nice To Haves

Bachelor's degree in Business or a related field.

Responsibilities

Perform high-quality reviews of payable and post-payment claims in a rapidly changing work environment.
Randomly review claims audited by Quality Control Examiners to ensure they meet a 98.00% quality score.
Maintain current and relevant claims auditing competencies for the types of claims being audited.
Stay current on claims regulation enhancements and updates, as well as company policies.
Review high-dollar claims of $125,000.
Maintain knowledge of First Pass, Provider Dispute Resolution (PDR), and Adjustments regulatory guidelines and turnaround time frames for all lines of business.
Work with Claims Compliance to research unclear regulatory processing guidelines.
Conduct audits of high-dollar claims, Provider Disputes, and Adjustments.
Work with the Claims Operations Supervisor to develop procedures that support departmental goals and improve work quality.
Research complex claims problems.
Perform other duties as assigned.