Senior Claims Auditor, Quality Assurance

Come Grow With Us
At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person - health, health care, and social services and supports - are met. We are seeking collaborators, innovators, and those who are driven to be their very best.

If you are looking for a career of purpose and are passionate about having an impact on society's health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.

About this role:

Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statement(s)

* Conduct audit reviews of processed claims (both processor and auto-adjudicated claims).
* Perform high quality review of payable and post payment claims in a rapidly changing work environment.
* Ensure that claims are paid or denied accurately in a timely manner and in accordance with internal and external regulations and guidelines through auditing activities.
* Ensures remaining current on all enhancements and updates to claim regulations and company policies
* Analyze, audit and reconcile Department of Health Care Services (DHCS) rate adjustments by working with internal and external resources as described in Operations process flows
* Responsible for High Dollar Claim review of 125K, current knowledge of First Pass /Provider Dispute Resolution (PDR)/Adjustments regulatory guidelines
* Participates in Root Cause Analysis (RCA) for recurring quality issues, compliance gaps, or service failures.
* Collaborate with internal teams to develop and implement corrective actions. Validates the effectiveness of remediation efforts through follow-up audits
* Ensures and maintains claims auditing competencies are current and relevant for the types of claims they are auditing.
* Prepares detailed audit reports summarizing findings, trends, error types, and opportunities for improvement. Tracks performance results at the individual, team, and process level. Presents audit insights to leadership
* Work collaboratively with internal staff to identify manual processes, potential problems, and risk areas and seek automated solutions. Assist in the preparation of requested materials for internal and external regulatory audits.
* Conduct post-configuration audit of claims system to ensure claim processing results are as expected.
* Identify and suggest additional audit needs based on observed data and trends.
* Works with Claims Compliance Department to research gray areas as it pertains to regulatory processing guidelines.
* Other projects and duties as assigned.

POSITION QUALIFICATIONS
* At least 4 years of claims processing experience in a Health Plan environment. At least 2 year of experience as a claims auditor/analyst.
* Prior experience working with Provider Dispute Resolution (PDR), third party liability, and coordination of benefit claims

SKILLS & ABILITIES

Solid working knowledge of Health plan and provider contracts, division of responsibility (DOFR), and CPT/ICD10 coding

Education:
* High School Graduate or General Education Degree (GED): Required
* Bachelor's Degree (four-year college or technical school) or Work Equivalent, preferred Field of Study: Claims Administration

Experience:
* 5 plus years of experience in auditing claims in a Managed Care environment required.
* 5 plus years of experience in processing professional, facility, and ancillary claims in Managed Care environment required.
* 5 plus years prior experience working with Provider Dispute Resolution (PDR), third party liability and coordination of benefit claims.

Computer Skills: Advanced computer skills included in the MS Office products.

Certifications & Licenses:
A current and valid California Driver's License and Insurance.

Other Requirements:

Knowledge of:

* Medi-Cal and managed care benefits. Medicare and DSNP a plus
* Claims processing and adjudication rules.
* Medical terminology, CPT codes, Revenue codes, HCPCS codes and ICD-10 codes
* Medi-Cal and/or Medicare requirements and regulations
* Strong claims compliance knowledge including turnaround time frames for all lines of business
* Solid understanding of complex contractual documents with recent experience interpreting Health Plan benefit documents.
* Good understanding of regulatory requirements pertaining to Medi-Cal and Medicare claims

Competency Statement(s)
* Analytical Skills - Ability to use thinking and reasoning to solve a problem.
* Research Skills -. Ability to conduct systematic, objective, and critical analysis.
* Judgment - The ability to formulate a sound decision using the available information.
* Communication, Oral - Ability to communicate effectively with others using the spoken word.
* Communication, Written - Ability to communicate in writing clearly and concisely.
* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

The estimated pay range for the position is:

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.