Claims Auditor - Managed Care

Location
California, United States
Salary
Competitive salary
Posted
24 Oct 2020
Closes
26 Oct 2020
Ref
HRC0337705
Job role
Audit
The Claims Auditor is responsible for working with the Managed Care Compliance Manager to ensure compliance with applicable rules and regulations including but not limited to AB1455 and Medicare Claims Processing Guidelines. Responsible for maintaining routine auditing functions and providing feedback on departmental activities to ensure ongoing compliance with all health plan and regulatory agencies, including CMS, DMHC, and DHCS.
Job Duties and Responsibilities:
  • Evaluates claims adjudication using standard principles and state specific policies and regulations in order to ensure accurate and timely claims adjudication
  • Performs moderately sophisticated claim audits on a routine basis for payment accuracy by following regulatory standards, and business policies
  • Assist manager with validation of health plan findings
  • Conducts quality assurance audits for claim adjustments, refunds and provider disputes
  • Performs focused reviews and provides reports to the Compliance team
  • Tracks and monitors all audit scores in database
  • Assists in preparing audit reports as requested.


Education:
  • High school diploma or GED required.
  • Associates degree or college diploma preferred.
Experience:
  • Five (5) years of experience with adjudication of all types of claims preferred.
  • Possess proven understanding of CPT, ICD, HCPCS, DRG coding, claims adjudication of hospital and professional claims and medical terminology.
  • Experience with EPIC System preferred.


  • Working Title: Claims Auditor - Managed Care
  • Department: MNS - Managed Care
  • Business Entity: Medical Network
  • City: Encino
  • Job Category: Finance
  • Job Specialty: Accounting
  • Position Type: Full-time
  • Shift Length: 8 hour shift
  • Shift Type: Day

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