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Senior Claims Auditor in Orange at Prospect Medical Systems

Date Posted: 10/15/2018

Job Snapshot

Job Description



Senior Claims Auditor

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Senior Claims Auditor is responsible for auditing and monitoring trends, and perform special analyses.  This individual will take the lead to ensure accurate and timely adjudication of claims, as well as identifying potential issues, and recommending strategies for resolution.  Individual is responsible for reviewing and analyzing complex project and reports results directly to management.  Apply claim and/or inquiry processing experience to audit and analyze simple to advanced-level claims processing procedures and workflows.



Job Responsibilities/Duties

  • Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows.  Assigned to handle second level review for high dollar claims prior to release of payment.  Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer.  

  • Handle complex and urgent special projects from external provider and internal departments.  Assist the PDR department with high profile projects. Must have the ability to accurately make the necessary adjustments for underpayments and review overpayment requests for Claims Recovery Specialist.

  • Assist Claims Trainer with analyzing Claim error trends.  Also serves as the primary back up for the Trainer in regards to Claims Change Form requests from the Contracting department.

  • Analyze and prepare Health plan claims selections for Annual health plan audit.  Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor are present at the time of audit.

  • Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests.  Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines.


Qualifications

Minimum Education: Bachelors Degree in related field.

Minimum Experience:  Previous 2 years experience as Medical Claims Auditor or 7 years previous experience examining Medical Claims.

Req. Certification/Licensure: None.  



Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance


How to Apply

To apply for this role, or search our other openings, please visit   http://pmh.com/careers/  and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm

Keywords: Claims, Auditing, Collections



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