Senior Claims Auditor (External Audit)

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

• 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.