Claims Quality Auditor II: High-Dollar & PDR Review

L.A. Care; Lancaster (CA); On-site; USD 67,000 - 87,000; Full time

Benefits offered by this job

Paid Time Off (PTO)

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Job summary

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.

Responsibilities

• 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.

Skills

Verbal communication

Written communication

Regulatory knowledge

Claims auditing

Education

Associate's Degree

Bachelor's Degree in Business or Related Field

Job description

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