Auditor, Compliance

Position Summary:

The Claims Compliance Auditor is responsible for performing activities related to benefit analysis and system design, manage special projects, claim denials and auto-adjudication applications as it applies to auditing and claims compliance. This includes oversight of all workflow, research and documentation under limited supervision by the Claims management. Identifies potential company risks and implements appropriate courses of action and develop strategies to reduce adjudication errors.

Analyzes all relevant information to track and trend the special projects outcomes to provide findings to appropriate management.

 Essential Duties and Responsibilities include the following:

1. Utilizes standardized processes, tools, methodologies and presentation templates, progress/milestone reports, track audit issues.
2. Communicates effectively with all appropriate internal and external individuals, as well as maintain regular contact with the Claims and Finance management and other project sponsors to coordinate project activities as appropriate.
3. Prepares and presents regular project progress reports for Claims management and other project sponsors such as Finance management as it relates to claims compliance.
4. Also works closely with other members of Finance and Claims management to plan project activities such as, but not limited to, Auto-adjudication, system pricing, training development based upon claims compliance.
5. Responsible for auditing denied
6. Responsible for assisting with health plan and regulatory audit preparations; such as scheduling, compile/vet audit universe reports, any additional documents required and results.
7. Responsible for assisting in development and testing of auto-adjudication
8. Ability to translate health benefit plan design, claims, health related insurance products into systems configuration.
9. Provides technical support, training assistance, and expertise to Claims staff or other department as determined through all phases of the project (e.g., Research, Outcomes, Provider notification of findings).
10. All other duties as directed by management

Organizational Responsibilities:

1. Proactively support and practice company mission, vision and values.
2. Follow Employee Handbook guidelines and company policies and procedures.
3. Follow established departmental dress code.
4. Appropriately and accurately maintain time keeping records.
5. Adhere to attendance policy and time off requests.
6. Follow safety policies and procedures.
7. Be flexible and adaptable and courteous and promote professionalism.
8. Communicate verbally and in writing through appropriate channels.
9. Maintain confidentiality at all times in compliance with company policy and HIPAA requirements.
10. Employee has completed all required annual Compliance training and signed attestation form is attached for each module.

 Compliance:

This position requires that the Employee abide by the Company’s Compliance Plan (including its Standards of Conduct) and all Compliance Policies and Procedures (as listed on the Company’s

Intranets or Internet pages under Compliance). This position further requires the Employee to act with the highest standards of integrity and professional ethics. This would include but is not limited to the expectation and requirement that the Employee immediately report any potential Compliance, Security or Privacy, or potential Fraud-Waste-Abuse violations or issues to the Company’s Compliance Officer, Compliance Hotline, and/or to any Officer of the Company. 

The pay range for this position at commencement of employment is expected to be between $30-32/hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

1. Education and/or Experience:

1. 5 years working knowledge of claims processing and system configuration, preferably EZCap or like systems in the healthcare system,
2. Strong ability to collaborate with management and other project managers to define business process issues, analyze operational efficiencies, implement creative solutions, and measure delivery results.
3. Should exhibit a disciplined, process and data-driven approach and
4. Knowledge of claims processing and regulatory agencies requirements
5. Requires strong organizational, communication and written
6. Must be able to function with minimal supervision and be able to prioritize all work
7. Demonstrated ability to conduct and interpret qualitative and quantitative analysis and problem-solving skills.
8. Ability to work well with individuals in all levels of the organization; must be an effective team player
9. Demonstrated ability to exercise initiative, independent judgment and be a self-
10. Strong PC-based business software skills including MS Office suite (Access, Excel, PowerPoint, Word).