NEOGOV · 2 weeks ago
Auditor (GARS)
United States
Full-time
Remote
Entry, Mid Level
$68K/yr - $109K/yr
2+ years expCalOptima is a mission-driven community-based organization focused on member health. They are seeking an Auditor (GARS) to audit provider disputes and grievance activities, ensuring compliance with health policies and regulations while supporting operational improvements.
GovTechHuman ResourcesInformation TechnologySoftware
Responsibilities
Auditing Functions
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
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
Preferred
3 years of experience auditing or reviewing provider dispute resolutions, appeals and grievances within a managed care or health plan environment
Experience with both Medicare and Medi-Cal billing and claims adjudication
Benefits
CalPERS pension program and additional retirement packages.
A generous PTO program
A quality work life balance
Various wellness programs
Tuition Reimbursement
Professional development opportunities
Career development opportunities
Flexible scheduling
Company
NEOGOV
NEOGOV is the leading provider of workforce management software uniquely designed for the public sector, education, and public safety.
501-1000 employees
H1B Sponsorship
NEOGOV has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (13)
2024 (10)
2023 (10)
2022 (18)
2021 (14)
2020 (16)
Funding
Current Stage
Late StageTotal Funding
$700MKey Investors
Warburg Pincus
2025-07-28Secondary Market· $700M
2025-07-28Acquired
2021-06-02Private Equity
Leadership Team
Shane Evangelist
CEO
Brandon McDonald
Head Of Marketing
Recent News
Canada NewsWire
2025-11-14
2025-11-14
Government Technology US
2025-10-31
Company data provided by crunchbase