Senior Claims Auditor: Lead for Complex Claims & Compliance

Cedars-Sinai; California (MO); On-site; USD 110,000 - 140,000; Full time

Job summary

Cedars-Sinai in Los Angeles, CA is seeking a Senior Claims Auditor to lead complex auditing initiatives, develop methodologies, and ensure CMS/DMHC compliance across Medicare and Commercial claims.

You will mentor junior auditors, lead cross‑functional audit projects with IT and compliance, perform EPIC/Tapestry testing, and deliver actionable reports to leadership that highlight risks and remediation steps.

Qualifications

• Minimum 5 years in professional/facility claims processing for Medicare and Commercial products.
• Experience developing audit methodologies and SOPs.
• 2 years in Senior/Lead claims auditing with regulatory compliance and system testing.

Responsibilities

• Designs, updates, and implements audit methodologies and selection criteria based on prior audit results, regulatory changes, system improvements, and operational trends.
• Conducts advanced audits on high risk and complex cases, ensuring compliance with policies, payment methodologies, and regulatory requirements.
• Performs EPIC/Tapestry system testing and validation to ensure claim processing systems and EIS updates function as intended.
• Serves as primary resource for internal audits, providing detailed validation and documentation.
• Develops, maintains, and updates departmental SOPs for claims auditing. Mentors and provides technical guidance to junior Claims Auditors.
• Analyzes audit results to identify trends, root causes, and systemic issues. Delivers actionable recommendations to management for process and operational improvements.
• Leads cross functional projects involving claims operations, IT, compliance, and other departments to resolve complex audit findings.
• Produces written and verbal reports summarizing audit findings for leadership, highlighting compliance risks and recommending mitigation strategies.
• Monitors appeals and disputes involving providers, members, and health plans, ensuring timely and accurate resolution of complex cases.
• Coordinates and manages multiple audit projects, ensuring deadlines and quality standards are met.
• Serves as a mentor and technical lead for Claims Auditors, providing guidance and training without direct supervisory authority.
• Coordinates team participation in special audits, ensuring consistency in methodology and reporting.

Education

Bachelor's degree in healthcare or related field

Tools

EPIC

Tapestry

Job description

Cedars-Sinai in Los Angeles, CA is seeking a Senior Claims Auditor to lead complex auditing initiatives, develop methodologies, and ensure CMS/DMHC compliance across Medicare and Commercial claims.

You will mentor junior auditors, lead cross‑functional audit projects with IT and compliance, perform EPIC/Tapestry testing, and deliver actionable reports to leadership that highlight risks and remediation steps.