Astrana Health
Overview
Join to apply for the
Senior Claims Auditor
role at
Astrana Health Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Compensation: $70,000 - $83,000 / year Department: Ops - Claims Ops Job Title: Senior Claims Auditor 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
Audit & Oversite
Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits
Review samples provided by clerical staff and ensure claims payments are accurate and all documentation required by the health plan auditor is present at the time of audit
Communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines
Respond to preliminary results by the due dates
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 providers and internal departments
Assist the Recovery Specialist in corresponding with external providers regarding claim overpayment requests
Audit Documentation/Reconciliation
Accurately document 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 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
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
Detailed knowledge of industry pricing methodologies (e.g., RBRVS, Medicare/Medi-Cal fee schedules, AP-DRG, APC)
Knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
Working knowledge of NCQA, DHS and HCFA standards
Knowledge of medical terminology with 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
Ability to analyze and process all levels of claims utilizing advanced CMS and DMHC regulations
Ability to present information and respond to questions from managers, employees, customers
Advanced reasoning, problem-solving, and planning skills
Ability to multi-task, prioritize, and work in a fast-paced environment with minimal supervision
Proficient in Excel to create and revise spreadsheets for accurate reports
A High School Diploma or Equivalent
2 years’ experience as Medical Claims Auditor or 7 years’ experience examining claims
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 and Medi-Cal guidelines
You’re great for the role if
Bachelor’s degree preferred
Environmental Job Requirements and Working Conditions
Hybrid work structure (in-office and remote on a weekly basis). Office: 1600 Corporate Center Dr., Monterey Park, CA 91754
Target pay range is $70,000.00 - $83,000.00; national target range for this role
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, veteran status, disability, or other legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at
humanresourcesdept@astranahealth.com
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.
Seniority level
Associate
Employment type
Full-time
Job function
Finance and Sales
Industries
Hospitals and Health Care
Referrals increase your chances of interviewing at Astrana Health by 2x
Get notified about new Claims Auditor jobs in Monterey Park, CA.
Universal City, CA $65,000.00-$80,000.00 2 weeks ago
Hawthorne, CA $80,000.00-$115,000.00 1 week ago
Los Angeles, CA $60,200.00-$128,800.00 2 weeks ago
Rosemead, CA $77,200.00-$115,800.00 6 days ago
Los Angeles Metropolitan Area $71,000.00-$135,000.00 3 weeks ago
Inglewood, CA $75,000.00-$85,000.00 2 months ago
Los Angeles Metropolitan Area $140,000.00-$160,000.00 2 weeks ago
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
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Join to apply for the
Senior Claims Auditor
role at
Astrana Health Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Compensation: $70,000 - $83,000 / year Department: Ops - Claims Ops Job Title: Senior Claims Auditor 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
Audit & Oversite
Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits
Review samples provided by clerical staff and ensure claims payments are accurate and all documentation required by the health plan auditor is present at the time of audit
Communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines
Respond to preliminary results by the due dates
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 providers and internal departments
Assist the Recovery Specialist in corresponding with external providers regarding claim overpayment requests
Audit Documentation/Reconciliation
Accurately document 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 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
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
Detailed knowledge of industry pricing methodologies (e.g., RBRVS, Medicare/Medi-Cal fee schedules, AP-DRG, APC)
Knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
Working knowledge of NCQA, DHS and HCFA standards
Knowledge of medical terminology with 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
Ability to analyze and process all levels of claims utilizing advanced CMS and DMHC regulations
Ability to present information and respond to questions from managers, employees, customers
Advanced reasoning, problem-solving, and planning skills
Ability to multi-task, prioritize, and work in a fast-paced environment with minimal supervision
Proficient in Excel to create and revise spreadsheets for accurate reports
A High School Diploma or Equivalent
2 years’ experience as Medical Claims Auditor or 7 years’ experience examining claims
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 and Medi-Cal guidelines
You’re great for the role if
Bachelor’s degree preferred
Environmental Job Requirements and Working Conditions
Hybrid work structure (in-office and remote on a weekly basis). Office: 1600 Corporate Center Dr., Monterey Park, CA 91754
Target pay range is $70,000.00 - $83,000.00; national target range for this role
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, veteran status, disability, or other legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at
humanresourcesdept@astranahealth.com
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.
Seniority level
Associate
Employment type
Full-time
Job function
Finance and Sales
Industries
Hospitals and Health Care
Referrals increase your chances of interviewing at Astrana Health by 2x
Get notified about new Claims Auditor jobs in Monterey Park, CA.
Universal City, CA $65,000.00-$80,000.00 2 weeks ago
Hawthorne, CA $80,000.00-$115,000.00 1 week ago
Los Angeles, CA $60,200.00-$128,800.00 2 weeks ago
Rosemead, CA $77,200.00-$115,800.00 6 days ago
Los Angeles Metropolitan Area $71,000.00-$135,000.00 3 weeks ago
Inglewood, CA $75,000.00-$85,000.00 2 months ago
Los Angeles Metropolitan Area $140,000.00-$160,000.00 2 weeks ago
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr