Claims Quality Auditor II

L.A. Care Health Plan•Los Angeles, CA

14d

About The Position

The Claims Quality Auditor II works closely with the Claims Quality Auditing Manager. The Claims Quality Auditor II maintains up-to-date knowledge of current trends and issues in healthcare, national and statewide standards and regulations, policies and procedures as well as have a solid understanding of the legal implications of Federal and State regulatory guidelines pertaining to claims processes. This position serves as a liaison between partnering departments i.e. Payment Integrity and Claims Compliance. This position works to ensure claims are being processed per regulatory guidelines as well as Medi-Cal guidelines and contractual agreements. This position conducts audits of high dollar claims, Provider Disputes and Adjustments. This position works with the Claims Operations Supervisor to develop procedures ensuring the achievement of goals and continuously works to improve the quality of work performed within the department. The Claims Quality Auditor researches on complex claims problems.

Requirements

Associate's Degree In lieu of degree, equivalent education and/or experience may be considered.
At least 4 years of claims processing experience in a Health Plan environment.
At least 3 years experience as a claims auditor/analyst.
Prior experience working with Provider Dispute Resolution (PDR), third party liability and coordination of benefit claims.
Solid understanding of complex contractual documents with 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.

Nice To Haves

Bachelor's Degree in Business or Related Field
Licenses/Certifications Preferred
Required Training
Physical Requirements Light

Responsibilities

Performs high quality review of payable and post payment claims in a rapidly changing work environment.
Perform random review of claims audited by the Quality Control Examiners to ensure they are meeting a 98.00% quality score for all work they perform within the department.
Ensures and maintains claims auditing competencies are current and relevant for the types of claims they are auditing.
Ensures to remain current on all enhancements and updates to claims regulations and company policies.
Responsible for High Dollar Claim review of 125K, current knowledge of First Pass /Provider Dispute Resolution (PDR)/Adjustments regulatory guidelines.
Strong claims compliance knowledge including turn around time frames for all lines of business.
Works with Claims Compliance Department to research gray areas as it pertains to regulatory processing guidelines.
Performs other duties as assigned.