Claims Quality Assurance Auditor

The Claims Quality Assurance Auditor maintains positive working relationships with our internal and external customers, health plan’s, providers and/or members by seeking a partnership approach that will meet the company goals and vision. The CQA auditor will coordinate Health Plan’s audits activities with preparation and provide preliminary results on non-compliant issues to CQA manager. Oversees, audit findings and provide education to claims staff and other internal customers within PIH. Assists 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. Oversees, 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. Adheres to internal department standard operating procedures and applies standard industry guidelines in accordance with regulatory agencies (state and federal). Researches, analyzes and resolves complex problems dealing with claims audits, including member denials, provider disputes, deficiencies that will potentially jeopardize the claims department. Has extensive knowledge of current and future claims processing, audits, compliance, adjustment, provider disputes, DOFRs and/or configuration, etc.

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.

Required Skills

• 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

Required Experience

Required:

• 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