Auditor - Provider Recovery (Hybrid Remote Options)

Date: Jan 14, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5175 

 

Position Summary/Position

 

Under the direction of the Provider Claims Resolution & Recovery Supervisor, the Provider Recovery Auditor is responsible for the audit and recovery of claims overpayments including COB and third-party liability.

Major Functions (Duties and Responsibilities)

 

1. Initiate and expand recovery opportunities through provided audit results, Provider calls, Third Party Liability and CCS eligible services.  
2. Audit payment errors that result in Provider refund checks to properly apply funds and determine the root cause.
3. Communicate with and answer Provider inquiries and/or Provider Disputes regarding the reason for the refund request based upon claims processing guidelines, contractual agreements involving the use of established payment methodologies, Division of Financial Responsibility, and regulatory guidelines.
4. Promote teamwork and maintain effective working relationships with others throughout the organization.

Supervisory Responsibilities

Leading: Self

Experience Qualifications

 

Four (4) years claims processing experience including Medicare and Medi-Cal. Two (2) years of experience auditing claims in a managed care environment including contract and financial DOFR interpretation. Experience with MS Office applications. 

Preferred Experience

Education Qualifications

 

High school diploma or GED required.

Preferred Education

 

Bachelor's degree from an accredited institution preferred.

Professional Certification

Professional Licenses

Drivers License Required

No

Knowledge Requirement

 

Knowledge of Medi-Cal and CMS guidelines for claim payments.

Skills Requirement

 

Strong analytical and problem-solving skills. Must be able to review cause and impact of problems and recommend realistic solutions both in writing and in meetings. Microsoft Office including being able to manipulate large data sets in Excel files. Excellent oral and written communication skills.

Abilities Requirement

 

Ability to build successful relationships across the organization. 

Commitment to Team Culture

 

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

 

Sedentary work in an office environment.

Physical Requirements

Keyboarding: Traditional - FREQUENTLY
Keyboarding: Other - FREQUENTLY
Use of computer mouse - FREQUENTLY
Hearing: One-on-One - FREQUENTLY
Hearing: In a group - FREQUENTLY
Hearing: Over the Telephone/Cell Phone - FREQUENTLY
Hearing: Conference Speakers/Video Calls/Radio Calls - FREQUENTLY
Turning/rotation of wrist or hand - FREQUENTLY
Communicate: Information/ideas verbally - FREQUENTLY
Alternate Sit/Stand or Walk at Will - FREQUENTLY
Near Visual Acuity - FREQUENTLY
Sitting - FREQUENTLY
Lighting - CONSTANTLY
Indoors - CONSTANTLY
Perform complex and varied tasks - FREQUENTLY
Develop and maintain positive work relationships - CONSTANTLY
Regular contacts: co-workers, supervisor - FREQUENTLY
Decision-making - FREQUENTLY
Lead/Influence Others - FREQUENTLY
Work review - FREQUENTLY
Rapid Pace of work - FREQUENTLY
Control of work pace - FREQUENTLY
Problem Solving - FREQUENTLY
Memory - FREQUENTLY
Understand and follow direction - FREQUENTLY
Regular and reliable attendance - CONSTANTLY

 

Starting Salary: $50,835.20  - $64,792.00  

Pay rate will commensurate with experience

 

Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.

 


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles