Senior Claims Auditor

Astrana Health, Inc.•Monterey Park, CA

4d•$70,308 - $80,000•Hybrid

About The Position

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.

Requirements

A High School Diploma or Equivalent
At least 2 years of experience as 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 required
Detail 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
Detail knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
Possess working knowledge of NCQA, DHS and HCFA standards
Knowledge of medical terminology combined with detail 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
Must have the ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC Regulations
Must possess the ability to effectively present information and respond to questions from managers, employees, customers
Must possess 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 to include 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

Nice To Haves

Bachelor’s degree preferred

Responsibilities

Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits
Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor are present at the time of audit
Requires the ability to communicate and analyze claims processing methodologies according to CMS and DMHC guidelines
Respond to preliminary results by the due dates
Requires the ability to respond to the corrective action plan timely and address the root cause appropriately as well as 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 provider and internal departments
Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests Audit Documentation/Reconciliation
Accurately document the 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 Collaboration
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