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CalOptima · 21 hours ago

Auditor (GARS)

Orange, CA

Full-time

Hybrid

Entry, Mid Level

$68K/yr - $109K/yr

2+ years exp

CalOptima is a mission-driven community-based organization focused on serving member health with excellence and dignity. They are seeking an Auditor (GARS) to audit provider disputes, grievance and appeal activities, ensuring compliance with health policies and regulations while providing actionable recommendations to leadership.

GovernmentHealth CareNon Profit

Comp. & Benefits

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

Conducts risk-based and targeted audits of grievances, appeals and provider disputes using CalOptima Health's approved tools consistent with all regulatory, contractual and accrediting standards and requirements

Assists with the development, revision and maintenance of all audit tools and score cards as necessary, to comply with state and federal regulatory requirements and internal department processes

Serves as a subject matter expert in the audit and review of provider disputes, appeals and grievances

Evaluates case classification accuracy, regulatory timeliness, documentation completeness and correct case closures

Compiles, summarizes and presents audit findings to department leadership, including recommendations for improvement

Develops and maintains reporting and trend analyses for leadership

Evaluates and audits case files to ensure cases were resolved within required regulatory timeframes and determines whether the correct case classification was applied appropriately in compliance with CalOptima Health policies, procedures, and regulatory requirements

Reviews grievance and appeal resolution letters to ensure member and provider concerns are accurately identified, addressed and resolved. Verifies language is appropriate for each line of business, and that complaint categories and codes are correctly applied

Audits appeals and provider dispute overturn decisions and validates that they are effectuated correctly, promptly and in accordance with all requirements

Collaborates with Training Program Coordinators and management to identify opportunities for training, system enhancements or workflow improvements related to grievances, appeals and provider disputes

Assists in the development, review and implementation of departmental policies and procedures

Completes other projects and duties as assigned

Qualification

AuditingGrievancesAppealsProvider Dispute ResolutionMedicare ExperienceMedi-Cal ExperienceAnalytical SkillsMicrosoft OfficeCommunication SkillsProject ManagementTeam Collaboration

Required

Bachelor's degree PLUS 2 years of experience in auditing, claims, grievances and appeals or provider disputes in a health care setting required, preferably in a managed care environment; 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

HMO, Medicare, Medi-Cal/Medicaid, Covered California and health services experience required