Claims Auditor, Managed Care (remote)

Job Description

Are you ready to bring your clinical competencies to a world-class Medical Group known for the very highest clinical standards? Do you have a passion for the highest quality and patient satisfaction? Then please respond to this dynamic opportunity available with one of the best places to work in Southern California! We would be happy to hear from you. The Cedars-Sinai Medical Network is committed to helping primary care and specialist physicians provide excellent care to all their patients, who benefit from convenient access to primary and specialty care physicians and seamless coordination of care between them. As a part of Cedars-Sinai, our physicians and staff are partners in quality health care from a medical center that is consistently recognized as one of the finest hospitals in the country. For the 8th consecutive year, we have been named one of the top 20 Physician Groups in Southern California by Integrated Healthcare Associates (IHA). Why work here? Beyond outstanding benefits, competitive salaries and health and dental insurance we take pride in hiring the best, most passionate employees. Our talented staff reflects the culturally and ethnically diverse community we serve. They are proof of our dedication to creating a dynamic, inclusive environment that fuels innovation and the gold standard of patient care we strive for. What will you be doing in this role? The Claims Auditor is responsible for ensuring the accuracy of claims processing based on department policies and procedures, CMS and DMHC regulations. Primary Duties and Responsibilities

• Conducts detailed audits for compliance with State, Federal and Health Plan regulatory requirements
• Conducts pre and post payment audits on adjudicated claims in compliance with Cedar-Sinai policies, procedures and payment methodologies
• Documents audit findings and presents errors to Claims Operations for corrections, root cause analysis and appropriate resolution
• Provides analysis and prepares recommendations to Management for errors and inconsistences
• Provides process improvement suggestions to Management Monitors appeals from providers, members and health plans to make sure they are processed accurately and in timely manner.
• Monitors the daily auditing of processed claims and letters for accuracy.
• Distributes and monitors multiple projects to make sure deadlines are met.

Qualifications

Job qualifications Education

• High School Diploma/GED required
• Bachelor's Degree healthcare or related field preferred

Work Experience

• 4 years of professional and facility claims processing for Medicare and Commercial products. Must be familiar with provider dispute resolution preferred
• 5 years of Senior/Lead or Claim Audit experience in a medical claim setting preferred

Remote Skills: Adjudication, Analysis Skills, Auditing, Claims Processing, Clinical Practices/Protocols, Content Management Systems (CMS), Health Plan, Health Plan Membership, Healthcare, Healthcare Quality, High School Diploma, Hospital, Managed Care, Medicare, Medicine, Multitasking, Patient Care, Primary Care, Process Improvement, Project Tracking, Regulations, Regulatory Requirements, Root Cause Analysis, Standards of Care, Time Management About the Company: Cedars-Sinai Medical Center Cedars Sinai is one of the largest nonprofit academic medical centers in the United States, and it is the largest private academic medical center in the Western United States. The Cedars Sinai main campus, which encompasses nearly 24 acres, is located at the point where the cities of Los Angeles, Beverly Hills, and West Hollywood meet. Cedars Sinai has been recognized annually by U.S. News & World Report’s top 10 best hospitals in the U.S. The institution most recently placed No. 7 among a select group of 20 Honor Roll hospitals and ranked nationally in a dozen specialties. In addition, Cedars Sinai ranked No. 3 in California and No. 2 in the Los Angeles metro area. Within Cedars Sinai, the Institute for Research on Health Aging conducts multi-disciplinary research that prioritizes the prevention of cardiovascular disease, neurocognitive disease, and cancer. Our focus is on translating new research discoveries into pragmatic interventions aimed at promoting healthy aging across diverse populations. Our approach involves human physiology, cohort, and clinical trial studies and our team includes established experts in population, clinical, translational, basic, and data science. Company Size: 10,000 employees or more Industry: Other/Not Classified Founded: 0 Website: http://www.cedars-sinai.org Apply To This Job