Specialty Health Plans Auditor III Claims at L.A. Care Health Plan

Los Angeles, California, United States -

Full Time

Start Date

Immediate

Expiry Date

03 Jan, 26

Salary

142166.0

Posted On

05 Oct, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Analytical Skills, Critical Thinking, Self-Starter, Motivator, Verbal Communication, Written Communication, Prioritization, Microsoft Office, Mentorship, Process Improvement

Industry

Hospitals and Health Care

Description

Salary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job Summary The Specialty Health Plans Auditor III Claims is responsible for all aspects of planning, execution, reporting and corrective action plans monitoring of claims processing compliance for specialty health plans and vendors. This includes medical, vision, dental, behavioral health, transportation, and telehealth services providers. These audits are intended to ensure that L.A. Care delegates are in compliance with applicable regulatory requirements and L.A. Care contractual agreements across all lines of business. The position is responsible for the Department of Managed Health Care (DMHC) claims data submissions for L.A. Care and its Plan Partners (PPs), and delegates done each quarter and annually. Primarily responsible for the creation, review, and submission of departmental policies and procedures annually. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff. Duties Performs annual claims audits for Specialty Health Plans and vendors. Provides timely and accurate deliverables to ensure claims processing are in compliance with regulatory and contractual requirements for plan partners, participating provider groups, capitated hospitals, specialty health plans, and vendors. Collaborates in the creation and implementation of standardized audit workpaper and reporting templates. Collects and completes quarterly and annual (DMHC) filing submissions. Serves as primary contact and liaison for Centers for Medicare and Medicaid Services (CMS) claim audit section of L.A. Care delegates. Reviews and updates annually the department’s Policies and Procedures (P&Ps). Ensures that any new or updated Policy and Procedure is reviewed and approved by management prior to submission. Supports the formalization of key internal processes and monitoring tools. Accountable for the completion of requests from Legal Department, Delegation Oversight’s monitoring oversight and reporting. Responsible for the overall communication and collaboration with interdepartmental personnel, leadership, specialty health plans, and vendors. Collaborates on the design, implementation, and reporting of special projects. Collaborates on the design and implementation of reports and tools for corrective action plan issuance and non-compliance notifications. Collaborates on the assessment, communication, and implementation of regulatory requirements that may impact internal processes. Duties Continued Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed. Performs other duties as assigned. Education Required Bachelor's Degree in Finance or Accounting or Related FieldIn lieu of degree, equivalent education and/or experience may be considered.Education Preferred Master's DegreeExperience Required: At least 4 years of experience performing claims audits or claims processing related to Medi-Cal, Medicare, and/or other managed care product lines similar to L.A. Care’s L.A. Care Covered and PASC-SEIU programs. Skills Required: Excellent analytical and critical thinking skills. Action-oriented, self-starter, and excellent motivator. Excellent verbal and written communication skills. Able to prioritize assignments, and able to independently with minimum supervision. Ability to interface professionally with both internal and external customers at all levels of the organization. Proficiency in Microsoft Office (Excel, PowerPoint, and SharePoint). Licenses/Certifications Required Licenses/Certifications Preferred Required Training Physical Requirements LightAdditional Information Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)

Responsibilities

The Specialty Health Plans Auditor III Claims is responsible for planning, execution, reporting, and monitoring of claims processing compliance for specialty health plans and vendors. This includes conducting audits to ensure compliance with regulatory requirements and contractual agreements.