Solugenix
Specialty Health Plans Auditor III, Claims
Solugenix, Los Angeles, California, United States, 90079
Specialty Health Plans Auditor III, Claims
Solugenix is assisting a client, a health insurance company, in their search for a Specialty Health Plans Auditor III, Claims. This is a 4+ month contract opportunity based out of Los Angeles, CA (Remote).
Base pay range $63.00/hr - $66.00/hr
The Specialty Health Plans Auditor III, Claims is responsible for various tasks within the Financial Compliance Unit, including the audit of claims processed by medical groups and health plans contracted with the client. This role works closely with the Supervisor and/or Lead Auditor on the identification and resolution of issues in a timely and efficient manner.
For Claims Emphasis: This position is responsible for all aspects of assigned claim audits, including audit testing and completion of the audit report. The role focuses on audits of contractual and regulatory compliance with timeliness and appropriateness standards, and covers complex areas of Medi‑Cal, Medicare, Covered California, and PASC‑SEIU benefits and processes. Additional tasks include claims data reporting in the Online Monitor Tool (OMT), compiling the Monthly Timeliness Report (MTR), completing financial statement analysis, and planning partner oversight of the Independent Practice Association (IPA) network on a quarterly & annual basis.
Acts as a Subject Matter Expert and serves as a resource and mentor for other staff.
Qualifications
Education Required: Bachelor's Degree. In lieu of a degree, equivalent education and/or experience may be considered.
Education Preferred: Master’s Degree.
Experience Required: Must have Managed care, health care, health insurance background, Healthcare Claims Audit, Financial Compliance background is a must. Minimum of 5 years performing claims audits or claim processing related to Medi‑Cal, Cal MediConnect, and/or other managed care product lines similar to the client’s Covered and PASC‑SEIU programs.
Nice‑to‑have skills: Expert knowledge of medical claims process, including Medicare, Medicaid.
Skills Required: Self‑motivated, detail‑oriented, able to prioritize assignments, work as part of a team, excellent verbal and written communication skills, professional interface with internal and external customers at all levels, flexible transportation for off‑site travel, knowledge of legislation and regulatory bodies affecting healthcare practices, medical records systems applications, insurance industry trends, health insurance products, market segments, and marketplaces.
Responsibilities
Perform auditing procedures under minimal supervision during audits of medical groups and health plans.
Provide timely and accurate reports indicating whether medical groups and health plans meet regulatory and contractual requirements.
Communicate issues and findings that would affect the audit results.
Perform claims audits for all medical groups and health plans contracted with the client.
Prepare audit reports presented to the supervisor within one week of the audit date.
Perform analysis of medical groups and plan partners.
Set up financial audit work papers; perform administrative functions for the audit team.
Set up complete and timely work papers before on‑site claims audits.
Perform other duties as assigned.
Additional Information Delegates: This position conducts sub‑delegation claims oversight audits of the PPGs, capitated hospitals, and the Plan Partners, including all claims processing sub‑contracting functions of the delegates.
Pay Range for CA, CO, IL, NJ, NY, WA, and DC: $63/hour to $66/hour. Starting rate may vary depending on factors including position offered, location, education, training and/or experience.
Solugenix will consider qualified applicants with a criminal history pursuant to the California Fair Chance Act and Ordinance. Applicants do not need to disclose their criminal history or participate in a background check until a conditional job offer is made. If a conviction directly related to the job is found, applicants will be given the chance to explain, provide mitigating evidence, or challenge the accuracy of the background report.
About The Client Our client is one of the world’s leading health insurance companies based out of Los Angeles, CA.
#J-18808-Ljbffr
Base pay range $63.00/hr - $66.00/hr
The Specialty Health Plans Auditor III, Claims is responsible for various tasks within the Financial Compliance Unit, including the audit of claims processed by medical groups and health plans contracted with the client. This role works closely with the Supervisor and/or Lead Auditor on the identification and resolution of issues in a timely and efficient manner.
For Claims Emphasis: This position is responsible for all aspects of assigned claim audits, including audit testing and completion of the audit report. The role focuses on audits of contractual and regulatory compliance with timeliness and appropriateness standards, and covers complex areas of Medi‑Cal, Medicare, Covered California, and PASC‑SEIU benefits and processes. Additional tasks include claims data reporting in the Online Monitor Tool (OMT), compiling the Monthly Timeliness Report (MTR), completing financial statement analysis, and planning partner oversight of the Independent Practice Association (IPA) network on a quarterly & annual basis.
Acts as a Subject Matter Expert and serves as a resource and mentor for other staff.
Qualifications
Education Required: Bachelor's Degree. In lieu of a degree, equivalent education and/or experience may be considered.
Education Preferred: Master’s Degree.
Experience Required: Must have Managed care, health care, health insurance background, Healthcare Claims Audit, Financial Compliance background is a must. Minimum of 5 years performing claims audits or claim processing related to Medi‑Cal, Cal MediConnect, and/or other managed care product lines similar to the client’s Covered and PASC‑SEIU programs.
Nice‑to‑have skills: Expert knowledge of medical claims process, including Medicare, Medicaid.
Skills Required: Self‑motivated, detail‑oriented, able to prioritize assignments, work as part of a team, excellent verbal and written communication skills, professional interface with internal and external customers at all levels, flexible transportation for off‑site travel, knowledge of legislation and regulatory bodies affecting healthcare practices, medical records systems applications, insurance industry trends, health insurance products, market segments, and marketplaces.
Responsibilities
Perform auditing procedures under minimal supervision during audits of medical groups and health plans.
Provide timely and accurate reports indicating whether medical groups and health plans meet regulatory and contractual requirements.
Communicate issues and findings that would affect the audit results.
Perform claims audits for all medical groups and health plans contracted with the client.
Prepare audit reports presented to the supervisor within one week of the audit date.
Perform analysis of medical groups and plan partners.
Set up financial audit work papers; perform administrative functions for the audit team.
Set up complete and timely work papers before on‑site claims audits.
Perform other duties as assigned.
Additional Information Delegates: This position conducts sub‑delegation claims oversight audits of the PPGs, capitated hospitals, and the Plan Partners, including all claims processing sub‑contracting functions of the delegates.
Pay Range for CA, CO, IL, NJ, NY, WA, and DC: $63/hour to $66/hour. Starting rate may vary depending on factors including position offered, location, education, training and/or experience.
Solugenix will consider qualified applicants with a criminal history pursuant to the California Fair Chance Act and Ordinance. Applicants do not need to disclose their criminal history or participate in a background check until a conditional job offer is made. If a conviction directly related to the job is found, applicants will be given the chance to explain, provide mitigating evidence, or challenge the accuracy of the background report.
About The Client Our client is one of the world’s leading health insurance companies based out of Los Angeles, CA.
#J-18808-Ljbffr