The Role
Lead and perform audits of health plan claims for DMHC/CMS compliance, document under/overpayments, analyze claims processes and error trends, coordinate corrective actions, collaborate across departments, and identify training needs.
Summary Generated by Built In
Job Title: Senior Claims Auditor
Department: Ops - Claims Ops
About the Role:
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.
Department: Ops - Claims Ops
About the Role:
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.
What You'll Do
- Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits
- 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
- Requires the ability to communicate and analyze claims processing methodologies according to CMS and DMHC guidelines
- Respond to preliminary results by the due dates
- Requires the ability to respond to the corrective action plan timely and address the root cause appropriately as well as 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 provider and internal departments
- Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests Audit Documentation/Reconciliation
- 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 Collaboration
- 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
- A High School Diploma or Equivalent
- At least 2 years of experience as Medical Claims Auditor and 5 years previous experience examining Claims
- Solid understanding of the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) rules and regulations governing claims adjudication practices and procedures required
- Detail knowledge and understanding of Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi-Cal fee schedule, All Patient Refined Diagnosis Related Groups (AP-DRG), Ambulatory Payment Classifications (APC), etc
- Detail knowledge of Medi-Cal, Medicare, Medicaid, and Commercial 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, ICD10, CRVS, RBRVS, CMS, ICE for Health Plan, DMHC and DHS fee schedules and CMS Medicare regulatory agencies, COB and Third-Party Liability recovery
- Must have the ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC Regulations
- Must possess the ability to effectively present information and respond to questions from managers, employees, customers
- Must possess 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 include the ability to create and revise Excel spreadsheets to provide accurate and clear reports
- 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
You’re great for the role if:
- Bachelor’s degree preferred
- Have experience using Ez-Cap and/or IDX
Environmental Job Requirements and Working Conditions
- This position is remotely based in the U.S. The home office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754.
- The target pay range for this role is between $70,308.00 - $80,000.00. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon 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 on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at [email protected] to request an accommodation.
Additional Information:
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.
About
Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient. Our platform currently empowers over 20,000 physicians to provide care for over 1.7 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.
Skills Required
- High School Diploma or Equivalent
- At least 2 years experience as Medical Claims Auditor or 7 years examining claims
- Solid understanding of DHCS and CMS rules and regulations governing claims adjudication
- Detailed knowledge of pricing methodologies (RBRVS, Medicare/Medi-Cal fee schedule, AP-DRG, APC)
- Detailed knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
- Working knowledge of NCQA, DHS and HCFA standards
- Knowledge of medical terminology and coding systems (CPT, HCPCS, DRG, REV, OPS, ASC, ICD10, CRVS)
- Familiarity with ICE for Health Plan, DMHC and DHS fee schedules, COB and third-party liability recovery
- Ability to analyze and process all levels of claims accurately using CMS and DMHC regulations
- Proficient in Excel, able to create and revise spreadsheets and reports
- Advanced reasoning, problem-solving, planning, and independent decision-making skills
- Ability to effectively present information and respond to questions from managers, employees, and customers
- Ability to multi-task, prioritize, and work in a fast-paced environment with minimal supervision
- Extensive knowledge of claims processing guidelines including prospective payment systems, DRG payment systems, comprehensive coding edits
- Bachelor's degree
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The Company
What We Do
Astrana Health is a physician-centric, technology-powered healthcare company that operates an integrated delivery platform. It enables providers to participate in value-based care arrangements, helping them deliver accessible, high-quality, and cost-effective care to patients. The company provides care coordination services to patients, primary care physicians, specialists, and health plans, leveraging proprietary technology to streamline operations and improve patient outcomes across local communities.
