Claims Quality Auditor

Job Category:  Claims
Department:  Claims
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  2990

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Claims Quality Auditor works closely with the Claims Quality Auditing Manager on reporting on Claims quality scores to provide feedback to Senior Management, Claims Operations, provider dispute resolution/Claims Adjustments and Claims compliance departments. This position audits claims for coding accuracy, benefit payment, contract interpretation, and compliance with policies and procedures.

Duties

Reviews work done by various units within the Claims department.  Perform random review of claims audited by the  Quality Control Examiners to ensure they are meeting a 98.00% quality score for all work performed within the Claims department including the Quality Control Claims Examiners. Ensures and maintains claims auditing competencies are current and relevant for the types of claims they are auditing including consistent and methodical review according to established guidelines meeting all deadlines (weekly/monthly) for claims quality reporting.  

Responsible for High Dollar Claim review . Research and assist claims compliance to define regulatory or accreditation requirements as needed. Work proactively with the Claims Audit Manager to ensure quality recommendations are made and implemented.  Ensure claims are being processed per regulatory guidelines as well as Medi-Cal guidelines and contactural agreements.

Maintains up-to-date knowledge of current trends and issues in healthcare, national and statewide standards and regulations, policies and procedures as well as have a solid understanding of the legal implications of Federal and State regulatory guidelines pertaining to claims processes to insure L.A. Care is using the most up to date guidelines to insure quality of the claims processed.Work with Claims Compliance Department to research gray area's as it pertains to regulatory processing guidelines.

Serve as a liason between partnering departments i.e.  Payment Integrity, Quality Configuration, Provider Network Management, and Claims Compliance including Claims Validation Analysts for effective collaboration.

Responsible for supporting quality initiatives through a variety of auditing activities; these activities include but are not limited to the review of work performed in the Claims departments. Contribute in the identification of opportunities to improve work processes and collaborate in the development of solutions to problems found in the work that is audited.

Performs other duties as assigned.

Education

High School Diploma/GED

Associate's Degree or Bachelor's Degree

Experience

Required:
With High School Diploma/GED: At least 5+ years claims processing experience in a Health Plan environment with at least 3 years experience as a claims auditor/analyst.

Prior experience working with PDR’s, third party liability and coordination of benefit claims.

Preferred: 
With Associate's Degree: 4 years claims processing experience in a Health Plan environment with at least 3 years experience as a claims auditor/analyst.

With Bachelor's Degree: 2-3 years claims processing experience in a Health Plan environment with at least 3 years experience as a claims auditor/analyst.

At least 3+ years prior experience in a Medi-Cal Managed Care Health Plan or Medicare Advantage Plan.

Recent prior experience as a Claims Auditor in a Medi-Cal Managed Care environment.

Required:
Solid understanding of complex contractual documents with recent experience interpreting Health Plan benefit documents.

Good understanding of regulatory requirements pertaining to Medi-Cal and Medicare claims.

Excellent written and verbal communication skills. Must be able to clearly state(verbally and written) what is identified as a deficiency or error in work being reviewed.                                                                                

Proficient use of Microsoft Office

Knowledge of ICD-10, CPT etc. Knowledge of medical records systems applications.

Proficient in data analysis

Knowledge of healthcare industry's trends, directions, major issues, regulatory considerations and trendsetters.

Knowledge and understanding of legislation and regulatory bodies affecting healthcare practices.

Knowledge of the insurance industry's trends, directions, major issues, regulatory considerations and trendsetters.

Knowledge of health insurance products, market segments and marketplaces.

Professional Licenses

Professional Certifications

Required Training

Additional Information

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)


Nearest Major Market: Los Angeles

Job Segment: Claims, Audit, Medical, Liability, Medicare, Insurance, Finance, Healthcare