Job Information

Providence Claims Quality and Compliance Auditor in Los Angeles, California


Claims Quality and Compliance Auditor - Hmo Claims Processing at Providence Facey Medical Foundation

We are seeking a Claims Quality and Compliance Auditor who will manage the claims internal audit functions, which includes audit process for adjudicated claims and encounters. Monitor check run process for accuracy. Develop policies and procedures for periodic claims audits and ensure compliance with affiliated health plans, client groups, and administrative contractual agreements. Designs, plans, directs and implements claims training programs for the organization, to include adaptations to changes in policies, procedures and technologies. Must be familiar with applicable State and Federal claim payment and denial timeliness legislation. Must be familiar with Timeliness Compliance pursuant to State and Federal rules and regulations. Must be well versed regarding the Provider Dispute Resolution tracking mechanism (AB1455). Responsible for ensuring customer (provider-vendor) satisfaction while maintaining the integrity of Facey's vision and business objectives. Demonstrates a high level of integrity and innovative thinking and actively contributes to the success of the Team. Supports, encourages and models attitudes, actions and behaviors that will make Facey the best in the industry in customer measured quality and responsiveness requirements. Serves as a liaison between contracted health plans, patients, hospitals and the Information Technology Dept. at Facey. Provides day-to-day assistance and training on Claims compliance matters to the Claims Examiners and Adjudication teams.

Required qualifications:

  • Bachelor's Degree

  • 10 or more years HMO claims processing and/or auditing experience in a managed care environment, preferably PMG/IPA setting within the last 7 years or any combination of education and/or experience which produces an equivalency

Preferred qualifications:

  • Comprehensive knowledge on claims reimbursement methodologies, data elements and coding

  • Strong knowledge of HMO membership, plan benefits, plan designs and health plans protocols on enrollment in a managed care environment

  • Extensive knowledge of medical terminology, HMO claims processing guidelines including EDI Claims, and government claim processing regulations

  • Knowledge of AB 1455 Provider Dispute Resolution Mechanism and its application according to ICE guidelines

  • Proficient with producing reports via Access and Excel, data analysis and ability make mathematical calculations

  • Must possess excellent oral and written communication skills and computer skills

  • Proficient use of Microsoft Word, Excel, Access, Outlook, and PowerPoint a must

  • Must display a high level of flexibility and attention to detail

  • Must possess excellent customer service and communication skills, be organized and a self-starter

Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.

About the hospital you will serve.

Facey Medical Group is a multi-specialty medical group with over 160 physicians providing care to the growing population in the North & East regions of Los Angeles & Ventura Counties. Twelve medical clinics, including two urgent care centers and dedicated women's centers, are located across the San Fernando, Santa Clarita and Simi Valleys. The group began as a single medical practice over 90 years ago.

Facey is part of Providence, an integrated, not-for-profit network of hospitals, care centers, medical clinics, affiliated services and educational facilities across Alaska, California, New Mexico, Montana, Oregon, Texas and Washington.

We offer a full comprehensive range of benefits — see our website for details —

About Providence

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

Requsition ID: P363971
Company: Providence Jobs
Job Category: Claims
Job Function: Revenue Cycle
Schedule: Full time
Shift: Day
Career Track: Admin Support
Address: CA Mission Hills 11165 N Sepulveda Blvd

Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.