Auditor (Claims)
Job Description
Department(s): Delegation Oversight
Reports to: Manager Audit & Oversight (Delegation)
FLSA status: Non-Exempt
Salary Grade: I - $61,000 - $99,110
Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is on
Monday, February 12, 2024 at 11:59 PM. Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. About CalOptima HealthAre you looking for a career that changes lives? As the single largest health plan in Orange County, CalOptima Health serves one in three residents with health insurance programs for low-income children, adults, seniors and people with disabilities. Our 1,500 employees are valued for their individual perspectives and contributions and benefit from flexible work schedules, recognition and opportunities to grow. If you're looking for a rewarding career supporting a meaningful mission, along with generous benefits and recognition, consider joining us at CalOptima Health!
About the PositionThe Auditor (Claims) will conduct routine oversight, monitoring and auditing of the Claims function within CalOptima Health, as well as externally delegated functions to ensure compliance with federal, state and accreditation standards.
Duties & Responsibilities: - Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
- Informs various departments within CalOptima Health and delegates/vendors of any changes to regulatory requirements.
- Conducts routine and pre-delegation audits of claims and other functional areas to ensure the delegates/vendors can perform the delegated activities, continue adherence to CalOptima Health's policies and procedures and comply with regulatory requirements.
- Participates and collaborates in workgroups that address internal activities for which CalOptima Health must demonstrate oversight and adherence to meet its contractual requirements with the Center for Medicare and Medicaid (CMS), California Department of Health Services (DHS), Department of Managed Health Care (DMHC) and any other applicable entity.
- Reports and tracks audit findings, identifies areas of concern and validation of remediation efforts, including identifying potential solutions (immediate and long term) and controls.
- Provides written and oral summaries of audit analyses as needed.
- Interprets and applies regulatory guidance, industry standards and audit protocols.
- Develops, updates and maintains audit tools and protocol templates.
- Provides technical support for assigned business areas.
- Completes other projects and duties as assigned.
Experience & Education: - Bachelor's degree in Health Care or related field required.
- 2 years of experience in processing medical claims required.
- 2 years of experience in a health care audit environment required, preferably in a managed care plan.
- An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
- Have access to means of transportation for work away from the primary office approximately 20% of the time.
Preferred Qualifications: - Experience working with FACETS.
Physical Demands and Work Environment:The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Physical demands: While performing duties of the job, employee may be required to move about the organization, as well as to offsite locations. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes and laptop to and from various locations, up to 25 pounds. Employee must be able to communicate, particularly for regular phone use, in meetings and face-to-face interaction. Employee must have means of transportation for offsite travel to health networks/physician medical groups, local meetings and health care delivery organizations 20% of the time.
- Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures.
About our Benefits & Wellness options:At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.
CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. Job Location: Orange, California
Position Type:
To apply, visit
https://jobs.silkroad.com/CalOptima/Careers/jobs/4521
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