Claims Quality Control Examiner II

Job Category:  Administrative, HR, Business Professionals
Department:  Claims

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  5369


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 Control Examiner II is responsible for collecting claims sample data from CAT (Claims Audit Tool) to perform audits. The Claims Quality Control Examiner II evaluates the adjudication of claims for all lines of business using standard principles and State and Federal policies and regulations. This position conducts audits of high dollar claims. This position researches claim problems to track, trend and report to the Claims Quality Supervisor to determine payment accuracy. The Claims Quality Control Examiner prepares, tracks and provides audit findings and reports findings according to designated timelines. He/she identifies and escalates process issues and/or system defects to appropriate team(s) and management. This position also identifies and escalates issues related to instructional material that is inaccurate, unclear or contains gaps and provides recommendations for correction of this material.


Audits professional and facility claims (pre- and post- payment) for staff based on pre-determined individual sample sizes and production goals.


Assists department to maintain a minimum quality level of 98.0% accuracy for statistical, financial and payment measurements. 


Ensures and maintains claims auditing competencies are current and relevant for the types of claims they are auditing. 


Ensures to remain current on all enhancements and updates to claims regulations and company policies. Informs management of any inappropriate provider billing or other adverse trends. Brings ideas to management to identify auto adjudication opportunities. 


Maintains a solid working knowledge of Health plan and provider contracts, division of responsibility (DOFR), and CPT/ICD10 coding. 


Perform other duties as assigned. 

Education Required
Associate's Degree
In lieu of degree, equivalent education and/or experience may be considered.
Education Preferred
Bachelor's Degree

At least 0-2 years of experience in professional and institutional healthcare claims examining and auditing.


At least 1 years claims auditing experience.


Strong knowledge and understanding of Managed Healthcare.


Excellent verbal and written communication skills.


Must be well versed in reading health plan DOFRs and understand all types of fee schedules, including risk pools.


Excellent knowledge of CPT, MS-DRG, APR-DRG, HCPCS and ICD-10 coding and regulations.

Licenses/Certifications Required
Licenses/Certifications Preferred
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, Medical, Insurance, Healthcare