Financial Compliance Auditor III Claims

Job Summary

The Financial Compliance Auditor III Claims is responsible for audits of claims processed by Delegated Participating Physician Groups (PPGs), hospitals and health plans contracted with L.A. Care and various tasks within the Financial Compliance Unit. This position works closely with management on identification and resolution of issues in a timely and efficient manner. This position is responsible for all aspects of assigned claim audits, including audit testing and completion of the audit report. This position is responsible for a variety of complex areas of the Medi-Cal, Medicare, Covered California, and PASC-SEIU benefit and process.  

The Auditor III reviews claims’ processing data to ensure that the delegated entities are compliant with federal and state regulations and contractual agreements. This position audits focuses on contractual and regulatory compliance with timeliness and appropriateness standards. This position is responsible for other ongoing tasks as assigned by management.

Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.

Duties

Performs auditing procedures under minimal supervision during the audits of PPGs, hospitals and health plans.

Conducts sub-delegation claims oversight audits of the PPGs, capitated hospitals, and the Plan Partners. This includes all claims processing sub-contracting functions of the delegates.

Provides timely and accurate reports that detail whether PPGs, hospitals and health plans are meeting certain regulatory and contractual requirements.

Presents timely reports to supervisor within one week of audit date. Additionally, reports any finding/issues that affect the audits results.

Prepares documentation needed prior to onsite claim audits timely.

Performs ongoing tasks as assigned by the manager of Financial Compliance which may include compiling Monthly Timeliness Report (MTR) and audit reports of the Plan Partner oversight of their Independent Practice Association (IPA) network on a quarterly & annual basis.

Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.

Performs other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 4 years of experience performing claims audits or claims processing related to Medi-Cal, Medicare, and/or other managed care product lines similar to L.A. Care’s L.A. Care Covered and PASC-SEIU programs.

Skills

Required:

Must be self-motivated.

Detail-oriented.

Able to prioritize assignments, multitask, and able to work as part of a team. 

Excellent verbal and written communication skills

Ability to interface professionally with both internal and external customers at all levels of the organization.

Proficient in Microsoft Excel & Word and data analysis.

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

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

Knowledge of health insurance products, market segments, and marketplaces.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information