Internal Auditor involved in executing operational, regulatory and financial audits globally within DLL. Collaborating with international professionals and engaging in stakeholder management.
About the role
- Claims Quality Auditor II ensuring compliance with regulatory guidelines and auditing high dollar claims at L.A. Care Health Plan. Collaborating with various departments to improve quality of claims operations.
Responsibilities
- Works closely with the Claims Quality Auditing Manager.
- Maintains up-to-date knowledge of current trends and issues in healthcare, national and statewide standards and regulations.
- Serves as a liaison between partnering departments (i.e. Payment Integrity and Claims Compliance).
- Conducts audits of high dollar claims, Provider Disputes and Adjustments.
- Develops procedures ensuring the achievement of goals and continuously improves the quality of work performed within the department.
- Researches complex claims problems.
Requirements
- Associate's Degree
- In lieu of degree, equivalent education and/or experience may be considered.
- At least 4 years of claims processing experience in a Health Plan environment.
- At least 3 years experience as a claims auditor/analyst.
- Prior experience working with Provider Dispute Resolution (PDR), third party liability and coordination of benefit claims.
- 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.
Benefits
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
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