Auditor, Provider Data

Auditor, Provider Data

Job no: 493816

Work type:
Full Time

Location:

505 City Parkway West

Categories:
Administrative

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

We are hoping you will join us as an Auditor, Provider Data and help shape the future of healthcare where you'll be an integral part of our Provider Data Operations team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders.

This position has been approved to be Full Telework.

If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

You will be responsible for conducting ongoing data quality auditing of Cal Optima Health's provider network data, which includes working with internal departments and health networks to remediate data errors. You will perform within the Provider Data Operations department to ensure that regulatory and internal guidelines are being followed in conjunction with Cal Optima Health's policies and procedures. You will provide analytical and administrative support specific to the Provider Data Operations department.

You will be responsible for auditing Cal Optima Health's provider data, which involves specialized background or knowledge regarding contract setup, provider data requirements, directories requirements and claims processing. You will often work independently and duties include research, analysis, documentation and reporting responsibilities. Together, we are building a stronger, more equitable health system.

• 95% - Auditing Functions
  • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
  • Assists with audits of the department's data entry activities into Cal Optima Health's provider data management systems.
  • Compiles and summarizes data reports and writes audit results to internal committees and meetings with recommendations for improvement.
  • Works with health networks, providers and internal departments to obtain audit information and presents findings and recommendations as appropriate.
  • Audits processes and activities to ensure accuracy and compliance for programs, including the provider directories, onboarding and term processes, health network data for network certification and adequacy and the 274 file.
  • Works with vendors and leverages internal and external tools to audit and improve provider data accuracy and integrity.
  • Reviews and break downs regulatory requirements to identify data impact for audit process updates and implementation.
  • Assists with implementing and monitoring Corrective Action Plans for regulatory compliance and/or operational compliance.
  • Maintains a well-documented audit trail.
  • Maintains ongoing reporting formats for use in data auditing and conducts independent analysis of audit results.
  • Maintains ongoing knowledge of provider data requirements and set up within the organization's provider management systems.
  • Analyzes regulatory audit requirements, develops workplans and processes.
  • Conducts data integrity activities to support Cal Optima Health's goal of maintaining a high rate of accuracy.
• 5% - Completes other projects and duties as assigned.

• Bachelor's degree in healthcare administration or related field PLUS 2 years of experience working with provider data in a health care or managed care environment required, preferably in a related area of responsibility,…