Senior Claims Auditor

Astrana Health; Monterey Park (CA); Hybrid; USD 70,000 - 83,000; Full time

Job summary

A leading healthcare organization is seeking a highly motivated Senior Claims Auditor in Monterey Park, CA. This role involves auditing health plan claims, ensuring compliance with CMS regulations, and collaborating with various departments. Ideal candidates will possess a solid understanding of claims processing, attention to detail, and the ability to work in a hybrid setting. The compensation ranges from $70,000 to $83,000 annually, based on experience. The company values diversity and is committed to equal opportunity employment.

Qualifications

• Solid understanding of DHCS and CMS rules governing claims.
• Detail knowledge of Medicare/Medi-Cal fee schedules.
• Experience with CPT, HCPCS, ICD10 coding.

Responsibilities

• Analyze and audit health plan claims selections.
• Document underpayments and overpayments accurately.
• Collaborate with various departments for effective resolution.

Skills

Knowledge of CMS Regulations

Medical Terminology

Data Analysis

Problem Solving

Excel Proficiency

Education

High School Diploma or Equivalent

Bachelor's Degree (Preferred)

Job description

Overview

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Compensation: $70,000 - $83,000 / year

Department: Ops - Claims Ops

About the Role: We are currently seeking a highly motivated Senior Claims Auditor. This role will report to the Director - Claims and enable us to continue to scale in the healthcare industry.

What You’ll Do

• Audit & Oversite — Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits
• Review samples provided by clerical staff and ensure claims payments are accurate and all documentation required by the health plan auditor is present at the time of audit
• Communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines
• Respond to preliminary results by the due dates
• Respond to corrective action plans timely and address the root cause and remediate the deficiency
• Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows
• Handle complex and urgent audit projects from external providers and internal departments
• Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests

• Audit Documentation/Reconciliation — Accurately document underpayments and overpayments into the audit database
• Assist management with analyzing Claim error trends
• Independently run reports on errors identified for potential error trends and report results to Claims management and Claims Trainer

• Collaboration — Build and maintain productive intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/Finance, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution
• Identify training needs/gaps for the team and ensure timely and effective training is imparted to all team members
• Other duties as assigned

Qualifications

• Solid understanding of the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) rules and regulations governing claims adjudication practices and procedures
• Detail knowledge of industry pricing methodologies (e.g., Resources-Based Relative Value Scale, Medicare/Medi-Cal fee schedule, AP-DRG, APC)
• Detail knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
• Working knowledge of NCQA, DHS and HCFA standards
• Knowledge of medical terminology with experience with CPT, HCPCS, DRG, REV, OPS, ASC, ICD10, CRVS, RBRVS, CMS, ICE for Health Plan, DMHC and DHS fee schedules and CMS Medicare regulatory agencies, COB and Third-Party Liability recovery
• Ability to analyze and process all levels of claims using advanced knowledge of CMS and DMHC Regulations
• Ability to present information and respond to questions from managers, employees, customers
• Advanced reasoning, problem-solving abilities and planning skills
• Ability to multi-task, prioritize and work in a fast-paced environment with minimal supervision
• Proficient in Excel to create and revise spreadsheets for accurate reports
• A High School Diploma or Equivalent
• Experience: Medical Claims Auditor or 7 years examining Claims
• Strong independent decision-making, influencing and analytical skills
• Extensive knowledge of claims processing guidelines including, perspective payment systems, DRG payment systems, coding edits, Medicare guidelines, and Medi-Cal guidelines

You’re great for the role if

• Bachelor’s degree preferred

Environmental Job Requirements and Working Conditions

• Hybrid work structure: work both in office and at home on a weekly basis. Office location: 1600 Corporate Center Dr. Monterey Park, CA 91754.
• National target pay range: $70,000.00 - $83,000.00. Actual compensation determined based on geographic location, experience, and other factors.

Astrana Health is an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender, sexual orientation, gender identity, age, veteran status, disability, or other protected characteristics. All employment is decided based on qualifications and business need. If you require assistance applying due to a disability, please email [e-mail] to request an accommodation.

Additional Information: The job description does not constitute an employment agreement and is subject to change by the employer as needs evolve.