PIH Health · 2 days ago
Claims Auditor (Onsite)
Whittier, CA
Full-time
Onsite
Senior Level
$21.50/hr - $35.46/hr
5+ years expPIH Health is a nonprofit, regional healthcare network serving approximately 3 million residents in the Los Angeles County area. The Claims Quality Assurance Auditor is responsible for maintaining positive relationships with customers and overseeing audit activities to ensure compliance and accuracy in claims processing. This role involves developing audit checklists, conducting root cause analysis, and providing education to claims staff to prevent non-compliance.
Health Care
Responsibilities
Maintain positive working relationships with our internal and external customers, health plan’s, providers and/or members
Coordinate Health Plan’s audits activities with preparation and provide preliminary results on non-compliant issues to CQA manager
Oversee audit findings and provide education to claims staff and other internal customers within PIH
Assist with developing an audit control checklist for prevention of claims timeliness, payment accuracy, systematic or statistical errors in PIH managed care claims system
Develop a root cause analysis report for common trends to provide feedback to the claims staff/team and/or PIH internal customers
Oversee, in conjunction with the Managed Care Management Team, to ensure QA programs are aligned with claims operations and other areas that have direct impact with claims to prevent non-compliance
Adhere to internal department standard operating procedures and apply standard industry guidelines in accordance with regulatory agencies (state and federal)
Research, analyze and resolve complex problems dealing with claims audits, including member denials, provider disputes, deficiencies that will potentially jeopardize the claims department
Qualification
Required
Computer system skills/knowledge (MS Excel and Word)
Written and verbal communication skills
Managed Care Knowledge and confidence exposure and expected
Knowledge of claims processing, CPT/RBRVS/ICD codes
Level of comprehension as it relations to regulatory compliance and guidelines associated with the following: CMS, DMHC, DOI, DHS, etc
Analyze data understanding the trends
Identifies compliance gaps in processes and systems by providing a risk based solution for prevention
Prepares, issues, and tracks deficiencies noted during claims pre/post audit and inspection
Extensive knowledge on root cause analysis/trends
Organizational skills
Ability to work independently with minimum supervision
Meet deadlines and completion on assigned projects in a timely manner
Ability to take initiative in analyzing problems, developing a solution with a win-win approach
Confidentiality and Honesty with compliance
Great customer service skills with internal and external customers
Communicate with CQA manager
Five (5) to 10 years claims processing experience
Claims auditing and understanding claims processing in a claims department
Experience with implementation of Corrective Action Plan (CAP)
Knowledge of regulatory requirements (CMS and DHS)
High School Diploma or equivalent
Preferred
Bachelor's Degree preferred
Company
PIH Health
PIH Health is a nonprofit, regional healthcare network.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Charlotte A. Weaver
PIH Health, Vice Chair, Finance Committee, Audit Committee, Executive Committee
Recent News
2025-11-10
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