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Provider Auditor

Date: Aug 9, 2019

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

 

 

POSITION PURPOSE

Under the direction of the Claims Audit & Recovery Manager and Senior Provider Auditor, the Provider Auditor is responsible for performing all aspects of the claims oversight requirements to audit, monitor, document and report the overall level of compliance of IEHP’s delegated Providers to ensure regulatory compliance and contractual requirements are met.

 

MAJOR RESPONSIBILITIES

 

  1. Conduct claims audits of IEHP’s delegated Providers to ensure they comply with State and Federal regulatory standards as well as IEHP contractual requirements.
  2. Perform on-site auditing of delegated Provider’s claims payment and denial processes, payment practices and dispute resolution mechanism in accordance with DHCS, DMHC and CMS contractual requirements to ensure compliance.
  3. Identify potential risk exposure to IEHP or its Providers or Members due to claims processing practices and systems used by delegated Providers.
  4. Conduct closing meetings and/or exit interviews with delegated Providers to provide a preliminary overview of the completed audit results and to inform them of the next steps in the audit process.
  5. Communicate audit results, areas of concern, recommendations for improvement and corrective action plan requests to appropriate IEHP personnel by means of written reports.
  6. Follow-up and assist Providers with corrective action plans (CAPs) as needed to ensure compliance.
  7. Review and analyze monthly, quarterly and annual compliance reports and keep abreast of any issues by communicating with the Regulatory Reporting Analyst.
  8. Perform other duties as required to insure the Health Plan operations are successful.
  9. Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP's policies and procedures relating to HIPAA compliance.
  10. Promote teamwork and maintain effective working relationships with others throughout the organization.

 

MINIMUM QUALIFICATIONS

 

Education/License:

Bachelor’s degree from an accredited four (4) year institution preferred or four (4) years of experience in lieu of degree.  Possession of a valid California driver’s license and valid automobile insurance.

 

 

Experience:

Four (4) years managed care experience in claims processing, two (2) years claims auditing experience and two (2) years experience working with Providers preferred.   

 

 

Knowledge/Skills Required:

Working knowledge of Medical Group and HMO operations and full risk coordination and delegation. Solid understanding of DMHC, DHCS and CMS regulations for claims adjudication practices and procedures for Medi-Cal and Medicare claims.  Thorough understanding of HCFA regulations governing claims payment procedures.  Working knowledge of audit processes and protocols, strong organizational skills, effective writing and communication skills and computer proficient.  Ability to interact with all levels of management and establish and maintain strong business relationships with plan partners.

Starting Salary: $54,724  - $69,784  

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