Quality Control Auditor

LSMA Management, Inc.; California (MO); On-site; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare organization is seeking a Quality Control Auditor – Claims Management to ensure accuracy and compliance in claims processing. The role involves auditing claims activities, identifying trends, and ensuring adherence to federal and state regulations. Candidates should have substantial experience in managed care claims auditing with a focus on detail and regulatory standards. Preferred qualifications include relevant degrees and certifications. This position supports operational improvement while minimizing financial risk.

Qualifications

• Minimum five years of managed care claims auditing or related experience.
• Preferred certifications include CPC, CPMA, or CPCO.
• Strong knowledge of CPT, HCPCS, ICD-10, and reimbursement methodologies.

Responsibilities

• Perform detailed audits of claims processing activities.
• Evaluate claims adjudication performed by Claims Examiners.
• Support managed care compliance through auditing claims.

Skills

Managed care claims processing knowledge

Analytical and problem-solving skills

Attention to detail

Communication skills

Proficiency with claims systems

Education

High School Diploma or equivalent

Associate’s or Bachelor’s degree in relevant field

Tools

EZ Cap

Microsoft Office

Job description

JOB SUMMARY

The Quality Control Auditor – Claims Management is responsible for performing detailed audits of claims processing activities to ensure accuracy, regulatory compliance, and adherence to contractual, coding, and reimbursement requirements within the Managed Services Organization (MSO). This role evaluates claims adjudication performed by Claims Examiners, identifies errors, analyzes trends, and provides recommendations to improve claims accuracy, operational efficiency, and compliance with federal and California regulatory standards.

The Quality Control Auditor supports delegated managed care compliance by auditing claims in accordance with health plan contracts, coding standards, reimbursement methodologies, and applicable regulatory requirements, including Department of Managed Health Care (DMHC), Centers for Medicare & Medicaid Services (CMS), and Department of Health Care Services (DHCS) standards where applicable.

This role plays a critical role in maintaining claims processing integrity, minimizing financial risk, ensuring regulatory compliance, and supporting continuous operational improvement.

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High School Diploma or equivalent.

Preferred: Associate’s or Bachelor’s degree in Healthcare Administration, Business Administration, Compliance, or related field.

Experience

• Minimum: At least five years of managed care claims auditing, claims examiner, or claims quality control experience. Two years of experience as a Claims Examiner or Claims Adjuster.
• Preferred: Experience in MSO, IPA, or health plan environment. Experience supporting delegated managed care and regulatory audits. Experience auditing professional and institutional claims.

Certification(s)

• Preferred: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Professional Compliance Officer (CPCO)

Skills, Knowledge & Abilities

• Strong knowledge of managed care claims processing and audit methodologies.
• Knowledge of CPT, HCPCS, ICD-10, DRG, and reimbursement methodologies.
• Knowledge of health plan contracts, fee schedules, and DOFR agreements.
• Knowledge of DMHC, CMS, DHCS, and regulatory requirements.
• Strong analytical and problem-solving skills.
• Ability to interpret and apply complex regulatory and contractual requirements.
• Strong attention to detail and audit documentation skills.
• Excellent written and verbal communication skills.
• Proficiency with claims systems such as EZ Cap and Microsoft Office applications.
• Ability to work independently and meet audit deadlines.
• Ability to maintain confidentiality and data integrity.