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Astrana Health · 1 day ago

Senior Claims Auditor

Monterey Park, CA

Full-time

Hybrid

Mid, Senior Level

$70K/yr - $83K/yr

2+ years exp

Astrana Health is currently seeking a highly motivated Senior Claims Auditor to join their team. This role involves auditing health plan claims and ensuring compliance with CMS and DMHC guidelines while collaborating with various departments to improve claims processing. The successful candidate will analyze claims, document findings, and assist in training team members on best practices.

Health CareMedical

Growth Opportunities

Responsibilities

Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits

Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor are present at the time of audit

Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines

Respond to preliminary results by the due dates

Requires the ability to 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 provider and internal departments

Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests

Accurately document the 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

Build and maintain productive & collaborative 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

Other duties are assigned

Qualification

Claims auditingCMS regulationsMedi-Cal guidelinesMedical terminologyExcel proficiencyAnalytical skillsMulti-taskingProblem-solving skillsCommunication skills

Required

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 required

Detail knowledge and understanding of Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi-Cal fee schedule, All Patient Refined Diagnosis Related Groups (AP-DRG), Ambulatory Payment Classifications (APC), etc

Detail knowledge of Medi-Cal, Medicare, and Medicaid program guidelines

Possess working knowledge of NCQA, DHS and HCFA standards

Knowledge of medical terminology combined with detail knowledge and 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

Must have the ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC Regulations

Must possess the ability to effectively present information and respond to questions from managers, employees, customers

Must possess advanced reasoning and problem-solving abilities and planning skills

Ability to multi-task, prioritize and work in a fast-paced environment under minimal supervision

Proficient in Excel to include the ability to create and revise Excel spreadsheets to provide accurate and clear reports

A High School Diploma or Equivalent

Previous 2 years' experience as Medical Claims Auditor or 7 years previous 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 guidelines, and Medi-Cal guidelines