Audit Lead
Posted on: 3 Oct 2021
Orange, CA
Job Description
Job Responsibilities/Duties
Analyze and prepare Health plan claims selections for all health plan/DMHC/CMS audits.
Maintain audit schedule.
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.
Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows.
Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines.
Handle complex and urgent audit projects from external provider and internal departments.
Accurately document the underpayments and overpayments into the audit database.
Assist management with analyzing Claim error trends.
Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer.
Log health plan audit findings to ensure root cause ensuring CAP remediation is complete.
Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/ Finance, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution.
Identify training needs/ gaps for the team and ensure timely and effective training is imparted to all team members.
Qualifications
Minimum Education: A High School Diploma or Equivalent required. BS/BA preferred.
Minimum Experience: Previous two (2) years’ experience as Medical Claims Auditor or 7 years previous experience examining Claims required. Demonstrated leadership skills, ability to coach, mentor and foster a culture of achievement. Strong independent decision-making, influencing and analytical skills. Extensive knowledge of claims processing guidelines including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines.
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, benefit eligible positions will receive:
Company 401K
Medical, dental, vision insurance
Paid time-off
Life insurance
Southern California Hospital
Culver City, CA
From the day it opened as an eight-bed clinic in 1925, Southern California Hospital at Culver City (SCH-CC) has dedicated itself to providing quality care to the culturally diverse populations of the Culver City and West Los Angeles communities. SCH-CC is part of the Southern California Healthcare System, which includes Southern California Hospital at Hollywood and Southern California Hospital at Van Nuys. With a combined bed capacity of over 570 beds, the three-hospital system represents the fourth-largest combined facility in the greater Los Angeles region.
Now at 420 beds, SCH-CC is a general acute care hospital that utilizes many of the latest medical treatments and technologies. The hospital offers a wide range of inpatient and outpatient acute care services, including an orthopedic center, cardiovascular services, acute rehabilitation, sub-acute care, psychiatric care and chemical dependency programs. Additionally, SCH-CC operates a 24-hour emergency services center, which serves as a paramedic receiving station and is staffed by board-certified emergency physicians and nurse specialists.
Our Mission
To improve the healing and wellness of the patients and communities we serve.
Our Vision
To serve our community with distinction through excellence in health care.
Our Values
Leadership
Accountability
Service
Excellence
Caring
Respect
Patients come first in everything we do. Our primary focus is on the complete care of the patient—in a healing environment, with compassionate hospitality and a collaborative team approach to ensure the best outcomes for our patients. You can be confident you are being taken care of by an expert medical staff utilizing some of the most advanced diagnostic and treatment technologies available. Yet, we never lose sight of the intangibles—from the friendly and helpful people in the admitting office to our dedicated staff members.
Our team of professionals is dedicated to providing for your health and comfort. You are not just our patient, you are our guest.
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IndustryHealthcare
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No. of Employees1001 to 5000
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Website
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Jobs Posted58
