California Licensed Claims Auditor

Job Summary

To ensure compliance with regulatory requirements, the remote California Licensed Claims Auditor will conduct detailed audits of claims processing, document findings, and provide recommendations while managing multiple projects in a full-time capacity.

Key responsibilities

• Conduct detailed audits for compliance with State, Federal, and Health Plan regulatory requirements
• Document audit findings and present errors to Claims Operations for corrections and root cause analysis
• Monitor appeals from providers, members, and health plans to ensure accurate and timely processing

Required qualifications

• High School Diploma/GED required; Bachelor's Degree in healthcare or related field preferred
• 4 years of professional and facility claims processing experience for Medicare and Commercial products
• 5 years of Senior/Lead or Claim Audit experience in a medical claim setting preferred
• Familiarity with provider dispute resolution preferred