Senior Claims Auditor (External Audit)

Astrana Health; Monterey Park (CA); On-site; USD 70,000 - 80,000; Full time

Job summary

Astrana Health is seeking a Senior Claims Auditor to join the Ops - Claims Ops team. The role focuses on analyzing and auditing health plan claims, ensuring accuracy, and aligning with CMS/DMHC guidelines. You will interact with multiple departments to resolve issues and lead audit initiatives.

Remote-based position in the U.S., with home office at Monterey Park, CA. Target pay aligns with the range provided and reflects experience and location in the healthcare sector.

Qualifications

• At least 2 years of experience as Medical Claims Auditor and 5 years previous experience examining Claims
• Detail knowledge of Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) rules and regulations governing claims adjudication practices and procedures required
• Detail knowledge of Medi-Cal, Medicare, Medicaid, and Commercial program guidelines
• Possess working knowledge of NCQA, DHS and HCFA standards
• Knowledge of medical terminology and CPT, HCPCS, DRG, REV, OPS, ICD10, CMS, DMHC and DHS fee schedules

Responsibilities

• 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 documentation is present
• Communicate and analyze claims processing methodologies according to CMS and DMHC guidelines
• Respond to preliminary results by the due dates
• Address corrective action plans timetly and remediate deficiencies
• Audit and analyze all levels of claims processing procedures and workflows
• Assist Recovery Specialist in correspondence regarding Claims Overpayment requests
• Document underpayments and overpayments in the audit database
• Assist management with analyzing Claim error trends
• Run reports on errors identified for potential error trends and report to management
• Build collaborative relationships across departments to identify and resolve issues
• Identify training needs and ensure timely training for team members

Skills

Claims auditing

Excel

CMS/DMHC guidelines

Analytical skills

Communication

Education

Bachelor's degree

Tools

Ez-Cap

IDX

Job description

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

Compensation: $70,308 - $80,000 / year

Department: Ops - Claims Ops

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

Compensation: $70,308 - $80,000 / year

Description

Job Title: Senior Claims Auditor
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

• Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits
• Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor are present at the time of audit
• Requires the ability to communicate and analyze claims processing methodologies according to CMS and DMHC guidelines
• Respond to preliminary results by the due dates
• Requires the ability to respond to the corrective action plan timely and address the root cause appropriately as well as 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 provider and internal departments
• Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests Audit Documentation/Reconciliation
• Accurately document the 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 the results to Claims management and Claims Trainer Collaboration
• Build and maintain productive & collaborative 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

Qualifications

• A High School Diploma or Equivalent
• At least 2 years of experience as Medical Claims Auditor and 5 years previous experience examining Claims
• 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 required
• Detail knowledge and understanding of Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi-Cal fee schedule, All Patient Refined Diagnosis Related Groups (AP-DRG), Ambulatory Payment Classifications (APC), etc
• Detail knowledge of Medi-Cal, Medicare, Medicaid, and Commercial program guidelines
• Possess working knowledge of NCQA, DHS and HCFA standards
• Knowledge of medical terminology combined with detail knowledge and 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
• Must have the ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC Regulations
• Must possess the ability to effectively present information and respond to questions from managers, employees, customers
• Must possess advanced reasoning and problem-solving abilities and planning skills
• Ability to multi-task, prioritize and work in a fast-paced environment under minimal supervision
• Proficient in Excel to include the ability to create and revise Excel spreadsheets to provide accurate and clear reports
• Strong independent decision-making, influencing and analytical skills
• Extensive knowledge of claims processing guidelines including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines

You’re great for the role if:

• Bachelor’s degree preferred
• Have experience using Ez-Cap and/or IDX

Environmental Job Requirements and Working Conditions

• This position is remotely based in the U.S. The home office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754.
• The target pay range for this role is between $70,308.00 - $80,000.00. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.

Astrana Health is proud to be an Equal Employment Opportunity and Affimative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at [e-mail] to request an accommodation.

Additional Information:

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.