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Providence Health & Services Claims Quality Compliance Auditor in Mission Hills, California


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Providence is calling a Claims Quality and Compliance Auditor (Full Time/Day Shift) to Providence Facey Medical Foundation in Mission Hills, CA.

Please upload a current resume reflecting all professional experience.

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.

In this position you will:

  • Deliver upon the service expectations of both our patients and fellow staff members by listening to their needs; engaging in positive interactions; and following through on promises made in a thoughtful, efficient, timely and courteous manner so that their total outcome is better than expected

  • Respect the dignity, confidentiality and privacy of patients

  • Work in a safe manner, adhering to general safety precautions and standards. Report any unsafe conditions to their supervisor and/or the safety hotline

  • Review additional information and pend letters for accuracy

  • Participate in meetings regarding the claim audit function in order to improve the process and resolutions

  • Review PDRs for determination and process AB1455 Appeals according to PDR procedures

  • Ensure Facey maintains, a log of all Provider Dispute Resolutions (PDR), and send acknowledgment letters timely, according to AB-1455 regulations

  • Ensure all policies and procedures created to support AB-1455, specifically relating to PDRs are current and accurate based on the ICE interpretation

  • Review healthplan correspondence demand letters and assure proper timely handling

  • Respond to complex or non-routine written inquires received from Provider Vendors, Hospitals and Members

  • Respond and review potential adjustment claims

  • Ensure proper application of contract, DOFR and interest calculations on adjusted claims

  • Act as a resource on processing urgent claims, special projects and special handling of other provider claims

  • Ensure proper application and process of overpaid claims

  • Participate in meetings and task forces relating to tactical planning or implementation as appropriate

  • Review cases involving overpaid claims and initiate appropriate collection or expense recovery action in accordance with established policies and procedures

  • Act as a resource to Claims Examiners regarding interpretation of Health Plan division of financial responsibility

  • Act as a resource to IT Department for testing new contracts loaded to the system as well as all maintenance processes that involve MCA (Managed Care Claims System of IDX)

  • Interact with the IT Department to ensure that contract rates are loaded and applied correctly to every claim payment situation

  • Identify third party liability claims and notifies supervisor

  • Interact with the Utilization Review Department ensuring that UR Authorization practices are operational to both UR and Claims Departments

  • Manage and handle special projects delegated by Supervisor or Senior Management


Required qualifications for this position include:

  • Bachelor's Degree Or equivalent education/experience.

  • 10 or more years HMO claims processing 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.

  • 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 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

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 comprehensive, best-in-class benefits to our caregivers. For more information, visit

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. 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.

Schedule: Full-time

Shift: Day

Job Category: Claims

Location: California-Mission Hills

Req ID: 315148