Job description

People are the most important asset of Imperial, for this reason the difference and plurality of people, equality of opportunities, non-discrimination and inclusion in the workplace are priority and strategic factors in the Organization. Imperial maintains a strong will to promote Diversity, Equity, and Inclusion, through inclusive leadership as a lever change and business sustainability.

Imperial Health Plan of California, Inc. is approved by California Department of Managed Health Care to offer full-service Medicare Advantage coverage, including a Medicare Advantage Prescription Drug plan, and a Chronic Condition Special needs plan over numerous counties in California. Through its affiliate, Imperial Insurance Companies, Imperial also offers Medicare Advantage plans in Texas, New Mexico, Utah, and Arizona.

Our Mission: To deliver valuable care so that members are healthy in body, mind, and spirit to achieve their inherent potential.

Our Vision: To deliver value based care that is clinically effective, sustainable, and achieves exceptional outcome.

JOB SUMMARY: Conducts audits for management to assess effectiveness of controls, accuracy of claims records and payments, efficiency of claims operations, and to recover claims overpayments. Audits all paid and denied claims to identify processing errors and coordinates with management to develop processing standards. Identifies and reports suggestions for operational efficiency improvements to management. Implements auditing guidelines and processes and creates policies and procedures for the internal auditing process. Implements random auditing process or hard copy claims. Develops forms for notification of audit results to claims staff. The Claims Auditor develops and runs claims processing system reports to assist in periodic monthly audit reporting. Claims Auditor also assists in the administration of recoveries for the overpayment of claims.

ESSENTIAL JOB FUNCTIONS:

1. Performs routine and moderately complex audits on individual, random, training, and focused claims to identify exceptions to established claims adjudication requirements.

2. Researches claim processing problems and errors to determine their origin and appropriate feedback to examiners, trainees, and distribution to management.
3. Participates in communication with claims department management regarding results of claims audit process, to improve claims processing and resolution.

4. Observes employee claims processing techniques to provide feedback to employees and management on uniform application of guidelines and processes.
5. Provides qualified data for incorporation into training programs, policies, and procedures.

EDUCATION/EXPERIENCE:

· High school graduate or equivalent.

· Associate degree (A.A) or equivalent from two-year college of technical school; some college courses, or six months to one year related experience and/or training; or equivalent combination of education experience.

· Must have at least 5+ years of applicable healthcare claims adjudication experience within the managed care industry for a level I or II and at least 4 years for senior level claims.

· Claims Auditor must have experience with EZ-Cap database software or comparable claims processing system and Windows 2000, including Outlook and Excel software.

SKILLS/KNOWLEDGE/ABILITY:

· Familiar with audit applications such as Virtual Examiner and Virtual Auth Tech

· Familiar with ICD-9, HCPCS, CPT coding, ASC, APC and MS-DRG pricing

· Familiar with CMS, DHMC Regulations, facility, and professional claim billing practices.

· Must have knowledge of multi-product line claims adjustment experience.

Job Type: Full-time

Pay: $29.00 - $35.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Referral program
• Vision insurance

Physical setting:

• Office

Schedule:

• 8 hour shift

Ability to commute/relocate:

• Pasadena, CA 91106: Reliably commute or planning to relocate before starting work (Preferred)

Education:

• High school or equivalent (Preferred)

Work Location: In person

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