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 Financial Compliance Auditor III Claims is responsible for various tasks within the Financial Compliance Unit, including audit of claims processed by medical groups and health plans contracted with L.A. Care. This role works closely with the Supervisor and/or Lead Auditor on 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 benefit and process. This position audits focuses on 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 Monthly Timeliness Report (MTR), completion of the financial statement analysis, and Plan Partner oversight of their Independent Practice Association (IPA) network on a quarterly & annual basis.

 

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

Duties

Perform auditing procedures under minimal supervision during the  audits of medical groups and health plans. Provide timely and accurate reports that detail whether medical groups and health plans are meeting certain regulatory and contractual requirements. Communicate issues and findings that would affect the audit results.

 

Perform claims audits for all medical groups and health plans contracted with L.A. Care. Timely audit reports presented to supervisor with one week of the audit date. Communicate issues and findings that would affect the audit results.

 

Perform analysis of medical groups and plan partners.

 

Set up financial audit work papers. Perform certain administrative functions for the audit team. Set up completely and timely work papers needed prior to going on site for the claims audits.

 

Perform other duties as assigned.

Duties Continued Education Required Bachelor's DegreeIn lieu of degree, equivalent education and/or experience may be considered.Education Preferred Master's DegreeExperience

Required:
A minimum of 5 years of experience performing claims audits or claims processing related to Medi-Cal, Cal MediConnect, and/or other managed care product lines similar to L.A. Care’s, L.A. Care Covered, and PASC-SEIU programs.

Skills

Required:
Must be self-motivated.

 

Detail-oriented.

 

Able to prioritize assignments, and able to work as part of a team.

 

Excellent verbal and written communication skills.

 

Ability to interface professionally with both internal and external customers at all levels of the organization.

 

Must also have flexible mode of transportation for considerable amount of travel to work off-site.

 

Knowledge and understanding of legislation and regulatory bodies affecting healthcare practices.

 

Knowledge of medical records systems applications.

 

Knowledge of the insurance industry's trends, directions, major issues, regulatory considerations and trendsetters.

 

Knowledge of health insurance products, market segments and marketplaces.

Licenses/Certifications Required Licenses/Certifications Preferred Required Training Physical Requirements LightAdditional Information

Delegates:  This position also conducts sub-delegation claims oversight audit of the PPGs, capitated hospitals and the Plan Partners. This includes all claims processing sub-contracting functions of the delegates.

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)