Internal auditor conducting operational, financial, and systems audits at RGE. Responsible for risk assessment and ensuring compliance across business units.
About the role
- Provider Recovery Auditor responsible for auditing claims overpayments and facilitating recovery opportunities. Supporting the Inland Empire Health Plan in achieving quality program goals.
Responsibilities
- Initiate and expand recovery opportunities through provided audit results, Provider calls, Third Party Liability and CCS eligible services.
- Audit payment errors that result in Provider refund checks to properly apply funds and determine the root cause.
- Communicate with and answer Provider inquiries and/or Provider Disputes regarding the reason for the refund request based upon claims processing guidelines, contractual agreements involving the use of established payment methodologies, Division of Financial Responsibility, and regulatory guidelines.
- Promote teamwork and maintain effective working relationships with others throughout the organization.
- Perform any other duties as required to ensure Health Plan operations and department business needs are successful.
Requirements
- Minimum of four (4) years of claims processing experience including Medicare and Medi-Cal
- Two (2) years of experience auditing claims in a managed care environment including contract and financial DOFR interpretation
- Experience with MS Office applications
- High School Diploma or GED required
- Bachelor’s degree from an accredited institution preferred
- Knowledge of Medi-Cal and CMS guidelines for claim payments
- Strong analytical and problem-solving skills
- Proficient in Microsoft Office, including being able to manipulate large data sets in Excel files
- Excellent oral and written communication skills
- Ability to build successful relationships across the organization
Benefits
- Medical Insurance with Dental and Vision
- Life, short-term, and long-term disability options
- Competitive salary
- State of the art fitness center on-site
- Career advancement opportunities and professional development
- Wellness programs that promote a healthy work-life balance
- Flexible Spending Account – Health Care/Childcare
- CalPERS retirement 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance
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