Claims Quality Auditor II
Job Category: Claims
Department: Claims Data and Support Services
Location: Los Angeles, CA, US, 90017
Position Type: Full Time
Requisition ID: 11594
Salary Range: $67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (Max.)
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.
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.
The Claims Quality Auditor II works closely with the Claims Quality Auditing Manager and maintains up-to-date knowledge of current trends and issues in healthcare, national and statewide standards, regulations, policies, and procedures. This position serves as a liaison between partnering departments such as Payment Integrity and Claims Compliance, ensuring claims are processed per regulatory and Medi-Cal guidelines.
Duties
- Performs high-quality review of payable and post-payment claims in a rapidly changing work environment.
- Conducts random reviews of claims audited by the Quality Control Examiners to ensure they meet a 98.00% quality score.
- Maintains current and relevant claims auditing competencies.
- Stays informed on enhancements and updates to claims regulations and company policies.
- Responsible for High Dollar Claim review of 125K; knowledgeable in First Pass /Provider Dispute Resolution (PDR)/Adjustments regulatory guidelines.
- Collaborates with Claims Compliance Department to research gray areas in regulatory processing guidelines.
Education Required
Associate's Degree (or equivalent education and/or experience may be considered).
Education Preferred
Bachelor's Degree in Business or Related Field.
Experience
Required:
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 with Provider Dispute Resolution (PDR), third-party liability, and coordination of benefit claims.
Skills
Required:
Solid understanding of complex contractual documents.
Good understanding of regulatory requirements for Medi-Cal and Medicare claims.
Excellent written and verbal communication skills.
Physical Requirements
Light
Additional Information
Salary Range Disclaimer: The expected pay range is based on factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including:
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
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