Medical Claims Audit Manager

The ideal candidate will have a strong foundation in Medi-Cal, Commercial, and Medicare benefits, with expertise in coordinating benefits. This role requires close collaboration with various departments to ensure that processes, programs, and services are executed efficiently and within the required timeframes. All work must align with company policies and procedures while complying with state and federal regulations, including CMS, Medi-Cal, and DMHC. The Claims Audit Manager is responsible for ensuring that claims are processed in accordance with company guidelines and contractual agreements, within set time limits, and according to provider contract rates. This position also oversees prepayment and post-payment validations, operational reporting, testing, and data submission management.

Key Responsibilities:

Prepare and manage complex regulatory and compliance reports for submission.
Assist with audit preparations by analyzing data, identifying deficiencies, and tracking corrective actions to completion.
Process and ensure smooth data entry into systems, troubleshooting any interruptions that arise.
Conduct data queries, analysis, and interpretation for ad hoc reporting.
Apply Medicare claim payment rules and requirements, including National and Local Coverage Decisions and Correct Coding standards, to claims received for payment.
Collect and organize information for compliance-related activities.
Contribute to quality assurance efforts for all department-related systems, applications, and process changes.
Perform pre-payment and post-payment audits to ensure accurate claim adjudication, coding, documentation, and fee schedule application.
Manage, analyze, and organize data from various sources, ensuring accuracy and proper narrative interpretation.
Provide detailed support to all claims staff on Medicare, Commercial, and Medi-Cal adjudication and coding requirements.
Update system coding sources as needed.
Exhibit excellent verbal and written communication skills.
Perform additional duties as required.
Minimum Qualifications:

At least five years of experience in healthcare claims processing or a combination of relevant education, training, and experience.
Experience with Medi-Cal and Medicare claim processing is preferred.
In-depth knowledge of claims processing workflows, payment rules, electronic billing processes, and universal billing forms.
Familiarity with CMS pricing tools and vendor pricing software.
Strong written communication skills for precise documentation within required timeframes.
Education & Experience:

3+ years of experience in an MSO, IPA, or Health Plan environment.
Highly organized, with the ability to manage multiple tasks effectively and strong knowledge of claims processing rules and guidelines.
Proficient with CPT and ICD9 codes and experienced in processing claims across all lines of business: Medicare, Medi-Cal, and Commercial.
Expertise in RBRVS, HCPCS, and CPT coding practices.
Knowledgeable about regulatory agencies such as CMS, DMHC, and DHCS (State of California).
Familiar with HIPAA Security & Privacy laws and Fraud, Waste, and Abuse regulations.
Understanding of managed care operations and related healthcare regulations.
Bachelor's degree or equivalent work experience required.
Ability to thrive in a fast-paced work environment.
Experience with software applications like EZCAP.

Desired Skills and Experience

The ideal candidate will have a strong foundation in Medi-Cal, Commercial, and Medicare benefits, with expertise in coordinating benefits. This role requires close collaboration with various departments to ensure that processes, programs, and services are executed efficiently and within the required timeframes. All work must align with company policies and procedures while complying with state and federal regulations, including CMS, Medi-Cal, and DMHC. The Claims Audit Manager is responsible for ensuring that claims are processed in accordance with company guidelines and contractual agreements, within set time limits, and according to provider contract rates. This position also oversees prepayment and post-payment validations, operational reporting, testing, and data submission management.

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance. To the extent our customers require a background check for certain positions, the Company faces a significant risk to its business operations and business reputation unless a review of criminal history is conducted for those specific job positions.