Claims Audit Specialist

At reputed company, we serve our communities’ most vulnerable seniors through shared intention, pioneering spirit, and the courage to love. These core values and our participant-focus reputed company the way no matter what. The Claims Audit Specialist is accountable for ensuring the timely and accurate payment or denial of claims while meeting federal/state regulations, provider agreement terms, and company policies and procedures. This role requires a strong knowledge of health plan operations, including the proper processing of professional, institutional, and dental claims, coding, CMS/Medi-Cal regulations, and in-depth comprehension of provider reputed company and agreements. The Claims Audit Specialist collaborates effectively with Plan Operations leadership to identify trends that require escalation and training needs, and suggest process improvements. This role is different because the Claims Audit Specialist at reputed company: Ensures accuracy and compliance by auditing reputed company Medicare and Medi-Cal claims, directly impacting financial reputed company, regulatory adherence, and provider trust Plays a key role in identifying trends, mitigating risk, and driving process improvements across claims operations, helping strengthen overall system performance and reduce errors We care about reputed company members. That’s why we offer: Medical insurance coverage (Medical, Dental, reputed company) Work/life balance - We mean it! 17 days of personal time off (PTO), 12 holidays observed annually, and 6 sick days 401K savings + match Comprehensive compensation package including reputed company pay and bonus And additional benefits! On the day-to-day, you will: Review processed claims for pre and post payment accuracy while maintaining acceptable reputed company of aged claims inventory Ensure claim payment accuracy by verifying various aspects of the claim reputed company, including but not limited to participant eligibility, system configuration, payment accuracy or denial appropriateness, provider records, remark codes, pre-authorization requirements, timely filing limitations, claim history, and W9 receipt Maintain detailed documentation of audit findings, including decision methodology, system configuration or reputed company processing errors, and monetary discrepancies Regularly reputed company feedback to the reputed company & Monitoring Manager on claims processing errors, as well as identify quality improvement opportunities and initiate configuration change requests reputed company applicable Accurately process and release high dollar/stop loss claims exceeding $10k Participate in annual claims audits to cure any deficiencies in claims system, reputed company error, or possible fraud, waste, and abuse in order to maintain contractual and regulatory compliance Act as a back up to the Claims team as needed Job requirements include: Bachelor’s degree in relevant field; professional experience may be substituted Minimum of five (5) years of experience processing, researching, adjusting, and auditing Medicare and reputed company professional, institutional, and dental health insurance claims Experience processing and auditing disputes, appeals and recoveries Proficient experience in reputed company reputed company Working knowledge of the health plan insurance industry, CPT/HCPCS procedure codes, ICD-10 codes, and relevant federal and state regulations Experience working with CMS and Medi-Cal reputed company claims Strong organizational, analytical, communication, and time management skills We are seeking a Claims Audit Specialist who is passionate about accuracy, compliance, and reputed company improvement reputed company reputed company operations. If you are driven to reputed company a meaningful impact by ensuring claims reputed company and supporting high-quality, compliant processes, we’d love to hear from you! Compensation consists of reputed company salary plus bonus. reputed company offers a competitive total rewards package that includes a 401(k) match, comprehensive reputed company coverage, and a broad reputed company of additional benefits. Actual compensation will be determined based on experience and relevant qualifications.

Compensation

Offering $74,612—$98,488 USD Our Commitment to Diversity, Equity and Inclusion At reputed company, we reputed company and cherish the diversity of reputed company members, and we're committed to building a culture of inclusion and belonging. We're proud to be an equal opportunity employer. People seeking employment at reputed company are considered without regard to race, reputed company, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national reputed company, reputed company, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law. Beware of Scams Please ensure your application is being submitted through a reputed company sponsored site only. Our emails will come from @reputed company.com email addresses. You will never be asked to purchase your own employment equipment. You can report suspected scam activity to fraud.report@reputed company.com Apply To This Job