Specialty Health Plans Auditor III, Claims

Specialty Health Plans Auditor III, Claims

Los Angeles, CA (Remote)

4+ Month Contract (Possibility of Conversion)

Job ID 25-09703

Solugenix is assisting a client, a health insurance company, in their search for a Specialty Health Plans Auditor III, Claims. This is a 4+ month contract opportunity based out of Los Angeles, CA (Remote).

The Specialty Health Plans Auditor III, Claims is responsible for various tasks within the Financial Compliance Unit, including the audit of claims processed by medical groups and health plans contracted with client. This role works closely with the Supervisor and / or Lead Auditor on the identification and resolution of issues in a timely and efficient manner.

For Claims Emphasis : This position is responsible for all aspects of assigned claim audits, including audit testing and completion of the audit report. This position is responsible for a variety of complex areas of the Medi-Cal, Medicare, Covered California, and PASC-SEIU benefits and processes. This position focuses on audits of contractual and regulatory compliance with timeliness and appropriateness standards. This position is responsible for other ongoing tasks as assigned by the Manager of Financial Compliance. These assignments may include claims data reporting in the Online Monitor Tool (OMT), compiling the Monthly Timeliness Report (MTR), completing the financial statement analysis, and planning partner oversight of their Independent Practice Association (IPA) network on a quarterly & annual basis.

Acts as a Subject Matter Expert and serves as a resource and mentor for other staff.

Qualifications : Education Required :

• Bachelor's Degree.
• In lieu of a degree, equivalent education and / or experience may be considered.

Education Preferred

Master's Degree

Experience Required :

Nice-to-have skills :

Skills Required :