Senior Claims Auditor

Location

1600 Corporate Center Dr., Monterey Park, CA 91754

$70,000 - $83,000 / year

Ops - Claims Ops

Senior Claims Auditor

We are currently seeking a highly motivated Senior Claims Auditor. This role will report to the Director - Claims and enable us to continue to scale in the healthcare industry.

• Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits
• Review provider samples by clerical staff and ensure claims payments are accurate and all documentation required by the health plan auditor are present at the time of audit
• Communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines
• Respond to preliminary results by the due dates
• Respond to the corrective action plan timely and address root cause appropriately and remediate the deficiency
• Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows
• Handle complex and urgent audit projects from external providers and internal departments
• Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests
• Accurately document underpayments and over payments into the audit database
• Assist management with analyzing claim error trends
• Independently run reports on identified errors for potential error trends and report results to Claims management and Claims Trainer
• Build and maintain productive collaborative intradepartmental relationships with department leads to enable effective and timely problem/improvement identification and resolution
• Identify training needs/gaps for the team and ensure timely effective training is imparted to all team members
• Perform other duties as assigned

• Solid understanding of DHCS, CMS rules and regulations governing claims adjudication practices and procedures required
• Detail knowledge and understanding of industry pricing methodologies including RBRVS, Medicare/Medicaid fee schedule, AP-DRG, APC, etc.
• Detail knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
• Possess working knowledge of NCQA, DHS, and HCFA standards
• Knowledge of medical terminology combined with detail knowledge and experience with CPT, HCPCS, DRG, REV, OPS, ASC, ICD
  10, CRVS, RBRVS, CMS, ICE for Health Plan, DMHC and DHS fee schedules and CMS Medicare regulatory agencies, COB and third‑party liability recovery
• Ability to analyze and process all levels of claims accurately utilizing advanced knowledge of CMS and DMHC Regulations
• Ability to effectively present information and respond to questions from managers, employees, customers
• Advanced reasoning and problem‑solving abilities and planning skills
• Ability to multi‑task, prioritize and work in a fast‑paced environment under minimal supervision
• Proficient in Excel to create and revise spreadsheets for accurate clear reports
• High School Diploma or equivalent
• Previous 2 years’ experience as Medical Claims Auditor or 7 years experience examining claims
• Strong independent decision‑making, influencing and analytical skills
• Extensive knowledge of claims processing guidelines including payment systems, coding edits, Medicare and Medi‑Cal guidelines

• Bachelor’s degree preferred

• Hybrid work structure: office at 1600 Corporate Center Dr., Monterey Park, CA and remote work on a weekly basis.
• Target pay range: $70,000.00 – $83,000.00.

Astrana Health is proud to be an Equal Employment Opportunity and affirmative action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need.

If you require assistance in applying for open positions due to a disability, please email us at humanre to request an accommodation.

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

Mid‑Senior level

Full‑time

Finance and Sales

Hospitals and Health Care