California Claims Audit Representative

Job Summary

A company is looking for a Claims Audit Representative to support accuracy, compliance, and quality in claims processing.

Key Responsibilities

• Audit pre lag reports for accuracy, completeness, and compliance
• Review and resolve member out of pocket (OOP) issues
• Monitor daily pre lag reports and escalate compliance issues as needed

Required Qualifications

• High school diploma or equivalent
• 3+ years of medical claims processing experience using EZCap or similar systems
• Knowledge of Medi-Cal and HMO claims payment regulations
• Claims auditing experience preferred
• Experience making payment determination decisions using Medicare and Medi-Cal guidelines is a plus