Claims Auditor - Managed Care

Employment Type

: Full-Time


: Accounting

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The Compliance Monitoring Specialist/Claims Auditor is responsible for working with the Managed Care Compliance Manager to ensure compliance with applicable rules and regulations including but not limited to AB1455 and Medicare Claims Processing Guidelines. Responsible for maintaining routine auditing functions and providing feedback on departmental activities to ensure ongoing compliance with all health plan and regulatory agencies, including CMS, DMHC, and DHCS.

Essential Duties and Responsibilities:

  • Evaluates claims adjudication using standard principles and state specific policies and regulations in order to ensure accurate and timely claims adjudication
  • Performs moderately complex claim audits on a routine basis for payment accuracy by following regulatory standards, and business policies
  • Assist manager with validation of health plan findings
  • Conducts quality assurance audits for claim adjustments, refunds and provider disputes
  • Performs focused reviews and provides reports to the Compliance team
  • Tracks and monitors all audit scores in database
  • Assists in preparing audit reports as necessary
  • Education:

    High school diploma or GED required. Associates degree or college diploma preferred.


  • Five (5) years of experience with adjudication of all types of claims required.
  • Possess strong knowledge of CPT, ICD, HCPCS, DRG coding, claims adjudication of hospital and professional claims and medical terminology; experience with EPIC System preferred

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