Claims Oversight Auditor - FWA (Remote Options)

Job Requisition ID: 5158

A reasonable salary expectation is between $57,948.80 - $73,860.80, based upon experience and internal equity.

Position Summary/Position

Under the general supervision of the Claims Oversight Supervisor, the Claims Oversight Auditor – FWA is responsible for auditing IEHP providers, giving feedback for billing process improvement and providing trending information to IEHP internal departments: Provider Services and Contracting. The Auditors will support the Compliance department by auditing providers to ensure the Plan meets Federal and State regulatory and contractual requirements for Fraud, Waste and Abuse.

Major Functions (Duties and Responsibilities)

1. Audit claims to ensure providers are billing correctly.
2. Provide feedback to Providers for billing process improvement through provider report cards.
3. Validate the effective implementation of Corrective Action Plans (CAPs) through future audits to ensure compliance.
4. Provide trending information to Provider Services and Contracting through reports and meetings to review data.
5. Report any possible FWA to the Compliance department.
6. Initiate and expand recovery opportunities by working with the Provider Resolution and Recovery department and the Reconciliation and Reporting department to develop standard audits.
7. Promote teamwork and maintain effective working relationships with others throughout the organization.

Experience Qualifications

Four (4) years auditing claims in a managed care environment including contract and financial DOFR interpretation. Two years (2) claims processing including Medi-Cal and Medicare.

Education Qualifications

High school diploma or GED required.

Preferred Education

Bachelor's degree from an accredited institution preferred.

Knowledge Requirement

Knowledge of Medi-Cal and CMS guidelines for claim payments.

Skills Requirement

Strong analytical and problem-solving skills. Must be able to review cause and impact of problems and recommend realistic solutions both in writing and in meetings. Microsoft Office including being able to manipulate large data sets in Excel files. Excellent oral and written communication skills.

Job Type: Full-time

Pay: $57,948.80 - $73,860.80 per year

Work Location: Hybrid remote in Rancho Cucamonga, CA 91730