Plan Operations Audit Specialist

WelbeHealth; Los Angeles (CA); On-site; USD 67,000 - 90,000; Full time

Job summary

WelbeHealth is seeking a Plan Operations Audit Specialist who will oversee claims processing and compliance audits for a value-based healthcare organization. This role demands a blend of analytical skills and thorough understanding of health plan operations, provider agreements, and regulatory standards, ensuring high-quality service to vulnerable senior populations.

Benefits

Health Coverage on Day 1

Paid Parental Leave

401K Match

17 days of paid time off in year one

12 company holidays

6 sick days

Career path advancement and leadership opportunities

Qualifications

• Bachelor’s degree in relevant field; experience may substitute.
• Minimum of 5 years in claims processing.
• 2 years with compliance audits.

Responsibilities

• Monitor participant eligibility updates and claims processing.
• Review claims functions for monthly audits and reporting.
• Assist in annual plan operations audits.

Skills

Healthcare claims processing

Compliance and regulatory audits

Provider agreements

Microsoft Suite applications

CPT/HCPCS procedure codes

ICD-10 codes

Education

Bachelor’s degree in relevant field

Job description

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Plan Operation Audit Specialist

WelbeHealth is a value-based healthcare organization that’s transforming the future of senior care by providing an all-inclusive care option to our most vulnerable senior population. We step in as the care provider and care planner that work to keep our participants within their communities, out of institutions, and cared for like family, all while receiving the healthcare and social services needed to thrive.

Plan Operation Audit Specialist

WelbeHealth is a value-based healthcare organization that’s transforming the future of senior care by providing an all-inclusive care option to our most vulnerable senior population. We step in as the care provider and care planner that work to keep our participants within their communities, out of institutions, and cared for like family, all while receiving the healthcare and social services needed to thrive.

The Plan Operations Audit Specialist will be accountable for validating various system configurations to ensure accurate processing of claims in accordance with provider agreements, regulatory guidelines, and company policy. The Plan Operations Audit Specialist will assist with the oversight, monitoring, and auditing of other functional areas within Health Plan Services, including Claims, Contracting, Credentialing and Provider Partnership.

Essential Job Duties:

• Monitor and validate participant eligibility updates and provider terminations to ensure timely updates to claims processing system
• Review performance of claims functions pertaining to claims processing and provider disputes in order to complete monthly audits and quarterly reporting
• Participate in annual plan operations audit to eliminate deficiencies and stay compliant from a contract and regulatory perspective
• Perform audits of provider Medicare/Medicaid/Medi-Cal enrollment, credentialing, and network adequacy
• Regularly provide feedback and detailed documentation of audit findings to Plan Operations leadership regarding configuration errors, and identify quality improvement opportunities when applicable
• Assist with the adjustment of audit tools to keep audit processes current
  
  

Job Requirements:

• Bachelor’s degree in relevant field; professional experience may be substituted
• Minimum of five (5) years of experience in healthcare claims electronic processing system
• Minimum of two (2) years of experience with compliance and regulatory audits
• Experience working with CMS and Medi-Cal based health plan operations
• Strong comprehension of provider contracts and agreements as it relates to claim reimbursement
• Proficient experience with all Microsoft Suite applications
• Working knowledge of the health plan insurance industry, CPT/HCPCS procedure codes, ICD-10 codes, and relevant federal and state regulations
  
  

Benefits of Working at WelbeHealth Apply your expertise in new ways as we rapidly expand. You will have the opportunity to design the way we work in the context of an encouraging and loving environment where every person feels uniquely cared for.

• BENEFITS: Health Coverage on Day 1, Paid Parental Leave, 401K Match.
• PERKS: 17 days of paid time off in year one, 12 company holidays, and 6 sick days
• GROWTH: Career path advancement and leadership opportunities
  
  

Salary/Wage base range for this role is $67,829 - $89,535 / year + Bonus + Equity. WelbeHealth offers competitive total rewards package that includes, 401k match, healthcare coverage and a broad range of other benefits. Actual pay will be adjusted based on experience and other qualifications.

Compensation

$67,829—$89,535 USD

COVID-19 Vaccination Policy

At WelbeHealth, our mission is to unlock the full potential of our vulnerable seniors. In this spirit, please note that we have a vaccination policy for all our employees and proof of vaccination, or a vaccine declination form will be required prior to employment. WelbeHealth maintains required infection control and PPE standards and has requirements relevant to all team members regarding vaccinations.

Our Commitment to Diversity, Equity and Inclusion

At WelbeHealth, we embrace and cherish the diversity of our team members, and we're committed to building a culture of inclusion and belonging. We're proud to be an equal opportunity employer. People seeking employment at WelbeHealth are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law.

Beware of Scams

Please ensure your application is being submitted through a WelbeHealth sponsored site only. Our emails will come from @welbehealth.com email addresses. You will never be asked to purchase your own employment equipment. You can report suspected scam activity to [e-mail]

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Accounting/Auditing and Finance

• Industries

  Hospitals and Health Care

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