Claims Oversight Auditor

3 weeks ago

Rancho Cucamonga, United States Inland Empire Health Plan Full time
What you can expect

Find joy in serving others with IEHP We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience

Under the direction of the Claims Oversight Supervisor, the Internal Claims Oversight Auditor is responsible for ensuring the compliance of IEHP’s claims payment system and processes by auditing claim payments using standard principles and State and Federal regulations. The auditors are also responsible for documenting and reporting findings and ensuring appropriate actions have been taken to resolve payment issues with the affected departments within IEHP, in addition to collaboration with, inter-departments to ensure member needs are met while simultaneously building strong peer relationships.

Major Functions (Duties and Responsibilities)

1. Audit internal systems and controls to ensure the claims system is set up correctly and claims are processed in accordance with contractual and regulatory requirements.
2. Prepare reports on audit results, identify trends, and implement quality improvement activities for improving business processes.
3. Initiate and expand recovery opportunities by working with the Provider Resolution and Recovery department and the Reconciliation and Reporting department to develop standard audits.
4. Ensure all payment fee schedules, procedure code files and regulatory bulletins are appropriately implemented and maintained timely.
5. Attend and actively participate in meetings with all levels of management to articulate audit findings and resolutions.
6. Promote teamwork and maintain effective working relationships with others throughout the organization.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

Competitive salary.
Hybrid schedule.
CalPERS retirement.
State of the art fitness center on-site.
Medical Insurance with Dental and Vision.
Life, short-term, and long-term disability options
Career advancement opportunities and professional development.
Wellness programs that promote a healthy work-life balance.
Flexible Spending Account – Health Care/Childcare
CalPERS retirement
457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance

Education & Experience

Four (4) years auditing claims in a managed care environment including contract and financial DOFR interpretation.
Two years (2) claims processing including Medi-Cal and Medicare.
High school diploma or GED required.

Key Qualifications

Yes, must have a valid California Driver's License.
Knowledge of Medi-Cal and CMS guidelines for claim payments.
Strong analytical and problem-solving skills. Must be able to review cause and impact of problems and recommend realistic solutions both in writing and in meetings. Microsoft Office including being able to manipulate large data sets in Excel files.
Excellent oral and written communication skills.

Start your journey towards a thriving future with IEHP and apply TODAY

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