Specialty Health Plans Auditor III Claims

Job Summary

The Specialty Health Plans Auditor III Claims is responsible for all aspects of planning, execution, reporting and corrective action plans monitoring of claims processing compliance for specialty health plans and vendors. This includes medical, vision, dental, behavioral health, transportation, and telehealth services providers. These audits are intended to ensure that L.A. Care delegates are in compliance with applicable regulatory requirements and L.A. Care contractual agreements across all lines of business.

The position is responsible for the Department of Managed Health Care (DMHC) claims data submissions for L.A. Care and its Plan Partners (PPs), and delegates done each quarter and annually.  Primarily responsible for the creation, review, and submission of departmental policies and procedures annually.

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

Duties

Performs annual claims audits for Specialty Health Plans and vendors.

Provides timely and accurate deliverables to ensure claims processing are in compliance with regulatory and contractual requirements for plan partners, participating provider groups, capitated hospitals, specialty health plans, and vendors.

Collaborates in the creation and implementation of standardized audit workpaper and reporting templates.

Collects and completes quarterly and annual (DMHC) filing submissions.

Serves as primary contact and liaison for Centers for Medicare and Medicaid Services (CMS) claim audit section of L.A. Care delegates.

Reviews and updates annually the department’s Policies and Procedures (P&Ps).  Ensures that any new or updated Policy and Procedure is reviewed and approved by management prior to submission.

Supports the formalization of key internal processes and monitoring tools.

Accountable for the completion of requests from Legal Department, Delegation Oversight’s monitoring oversight and reporting.

Responsible for the overall communication and collaboration with interdepartmental personnel, leadership, specialty health plans, and vendors.

Collaborates on the design, implementation, and reporting of special projects.

Collaborates on the design and implementation of reports and tools for corrective action plan issuance and non-compliance notifications.

Collaborates on the assessment, communication, and implementation of regulatory requirements that may impact internal processes.

Duties Continued

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.

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:

Excellent analytical and critical thinking skills.

Action-oriented, self-starter, and excellent motivator.

Excellent verbal and written communication skills.

Able to prioritize assignments, and able to independently with minimum supervision.

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

Proficiency in Microsoft Office (Excel, PowerPoint, and SharePoint).

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information