Claims Quality Auditor II

L.A. Care; Lancaster (CA); Sur place; USD 67 000 - 87 000; Plein temps

Avantages offerts par ce poste

Paid Time Off (PTO)

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Résumé du poste

The Claims Quality Auditor II at L.A. Care Health Plan, Los Angeles, CA, conducts high‑level reviews of payable and post‑payment claims within Medi-Cal guidelines.

You will coordinate with the Claims Quality Auditing Manager and other departments to ensure regulatory alignment and accuracy, with focus on high-dollar cases. Requirements include at least 4 years in claims processing in a health plan, 3 years as a claims auditor/analyst, and strong written/verbal communication along with regulatory

Qualifications

• At least 4 years of claims processing experience in a Health Plan environment.
• At least 3 years experience as a claims auditor/analyst.
• Experience with Provider Dispute Resolution (PDR), third party liability and coordination of benefit claims.

Responsabilités

• Performs high quality review of payable and post payment claims.
• Ensures 98.00% quality score for all work within the department.
• Responsible for High Dollar Claim review and regulatory guidelines.
• Works with Claims Compliance Department to research gray areas in processing guidelines.

Connaissances

Verbal communication

Written communication

Regulatory knowledge

Claims auditing

Formation

Associate's Degree

Bachelor's Degree in Business or Related Field

Description du poste

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Claims Quality Auditor II

Job Category: Claims

Department: Core Admin Ops - Claims Admin

Location: Los Angeles, CA, US, 90017

Position Type: Full Time

Requisition ID: 13400

Salary Range:$67,186.00(Min.) -$87,342.00(Mid.) -$107,498.00(Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

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.

Duties

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.

Education Required

Associate's Degree

In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Bachelor's Degree in Business or Related Field

Experience

Required:
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.

Skills

Required:
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.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Light

Additional Information

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care offersa wide range of benefits including

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program

Nearest Major Market: Los Angeles
Job Segment: Claims, Medicare, Accounts Payable, Audit, Insurance, Healthcare, Finance