Claims Quality Auditor II: High-Dollar Claims

L.A. Care; Los Angeles (CA); Presencial; USD 67 000 - 107 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Paid Time Off (PTO)

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Resumo da oferta

L.A. Care Health Plan in Los Angeles, CA is seeking a Claims Quality Auditor II to ensure claims processing complies with Medi-Cal and regulatory guidelines.

The role acts as a liaison between Payment Integrity and Claims Compliance, auditing high-dollar claims, provider disputes, and adjustments to meet a 98% quality target. The ideal candidate has at least 4 years in claims processing within a health plan, strong regulatory knowledge, and excellent written and verbal communication skills.

Qualificações

• Associate's Degree or higher; degree in related field preferred.
• At least 4 years of claims processing experience in a health plan.
• Experience as a claims auditor/analyst and with Provider Dispute Resolution (PDR).
• Strong knowledge of Medi-Cal and Medicare claims regulations.

Responsabilidades

• Performs high quality review of payable and post payment claims.
• Maintains 98.00% quality score across audits.
• Keeps current on claims regulations and company policies.
• Reviews high dollar claims, provider disputes and adjustments.
• Collaborates with Claims Compliance and other departments.

Conhecimentos

Regulatory knowledge

Communication skills

Claims processing

Provider disputes knowledge

Formação académica

Associate's Degree

Bachelor's Degree in Business or Related Field

Descrição da oferta de emprego

L.A. Care Health Plan in Los Angeles, CA is seeking a Claims Quality Auditor II to ensure claims processing complies with Medi-Cal and regulatory guidelines.

The role acts as a liaison between Payment Integrity and Claims Compliance, auditing high-dollar claims, provider disputes, and adjustments to meet a 98% quality target. The ideal candidate has at least 4 years in claims processing within a health plan, strong regulatory knowledge, and excellent written and verbal communication skills.