Position Summary:

The Senior Claims Compliance Auditor is responsible to evaluate and determine the appropriate action and to assist with performing activities related to Health Plan reporting, Audit preparation, Health Plan Audit Results and Corrective Action Plans, benefit analysis and system design, manage special projects 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 audit errors to provide findings to appropriate Claims management.

Essential Duties and Responsibilities include the following:

• Utilizes standardized processes, tools, methodologies and presentation templates, track audit issues.
• Assists Compliance Manager with oversight to ensure all health plan audit preparation, internal and external corrective action plans and internal audits are performed timely and efficiently as it relates to claims compliance.
• 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 health plan and regulatory audit results.
• Assist management with training needs to ensure compliance.
• Responsible for auditing compliance related IDM reports daily for accuracy and timeliness as a backup.
• Responsible for assisting with health plan audit preparations, audit results and corrective action plans.
• Responsible for assisting in development and testing of auto-adjudication applications.
• Provides technical support, training assistance, and expertise to Claims staff, Claims Compliance staff or other department as determined through all phases of a project (e.g., Research, Outcomes, Provider notification of findings).
• Performs other duties as assigned.

The pay range for this position at commencement of employment is expected to be between $24.00-$26.50/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.

Essential Duties and Responsibilities include the following:

• Utilizes standardized processes, tools, methodologies and presentation templates, track audit issues.
• Assists Compliance Manager with oversight to ensure all health plan audit preparation, internal and external corrective action plans and internal audits are performed timely and efficiently as it relates to claims compliance.
• 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 health plan and regulatory audit results.
• Assist management with training needs to ensure compliance.
• Responsible for auditing compliance related IDM reports daily for accuracy and timeliness as a backup.
• Responsible for assisting with health plan audit preparations, audit results and corrective action plans.
• Responsible for assisting in development and testing of auto-adjudication applications.
• Provides technical support, training assistance, and expertise to Claims staff, Claims Compliance staff or other department as determined through all phases of a project (e.g., Research, Outcomes, Provider notification of findings).
• Performs other duties as assigned.