Claims Oversight Auditor - Internal (Hybrid)

Date: Sep 21, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5154 


Position Summary/Position


Under the direction of the Claims Oversight Supervisor, the Internal Claims Oversight Auditor is responsible for ensuring the compliance of IEHP’s claims payment system and processes by auditing claim payments using standard principles and State and Federal regulations. The auditors are also responsible for documenting and reporting findings and ensuring appropriate actions have been taken to resolve payment issues with the affected departments within IEHP.

Major Functions (Duties and Responsibilities)


1. Audit internal systems and controls to ensure the claims system is set up correctly and claims are processed in accordance with contractual and regulatory requirements.
2. Prepare reports on audit results, identify trends, and implement quality improvement activities for improving business processes.
3. Initiate and expand recovery opportunities by working with the Provider Resolution and Recovery department and the Reconciliation and Reporting department to develop standard audits.
4. Ensure all payment fee schedules, procedure code files and regulatory bulletins are appropriately implemented and maintained timely.
5. Attend and actively participate in meetings with all levels of management to articulate audit findings and resolutions.
6. Promote teamwork and maintain effective working relationships with others throughout the organization.

Supervisory Responsibilities

Leading: Self

Experience Qualifications


Four (4) years auditing claims in a managed care environment including contract and financial DOFR interpretation. Two years (2) claims processing including Medi-Cal and Medicare.  

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

Yes, must have a valid California Driver's License.

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
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
Understand and follow direction - FREQUENTLY
Regular and reliable attendance - CONSTANTLY

A reasonable salary expectation is between $57,948.80  - $73,860.80, based upon experience and internal equity.


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