Healthcare Claims Auditor - La Palma, CA

    • Cerritos, CA

Position Description

The Healthcare Claims Auditor is responsible for reviewing all processed claims prior to payment release, and respond to Health Maintenance Organization (HMO) Enrollees for Commercial, Medicare, and Medicaid Enrollees. Responsible for daily auditing of managed care claim payments. Will be responsible to monitor claims compliance with Medicare by auditing reports. This person is the liaison with internal and external clients to resolve provider/member claim issues. Responsible to train claims examiners and is a resource relating to claims guidelines.

Primary Responsibilities

  • To perform daily audits of claims payments as established in the Claims Department Policies and Procedures
  • Work with Provider Disputes (PDR) and Appeals
  • To log all totals related to claims payment errors and examiner productivity for reporting purposes as established in the Claims Policies and Procedures
  • Trains claim examiners regarding the system and claim procedures
  • Audit pre check runs based on check run schedules
  • Run and resolve various claims reports prior to check run
  • Resolve claims based on CCI edit report to comply with CMS guidelines
  • Serves as a resource to Management, Customer service, UM and other departments on claim issues
  • To contribute to a fair and positive work environment by treating peers, superiors, subordinates, clients and vendor with professionalism and respect
  • We are looking for candidates with the following strong attributes:
    • Initiative - ability to thoughtfully and independently resolve problems
    • Organizational Skills - ability to prioritize individual and departmental workloads
    • Always follows through on work
    • Strong Reporting Skills
    • Technical and computer expertise
    • Communication - ability to identify and effectively communicate unresolved problems to Management in a timely manner
    • Teamwork/Workplace Civility - ability to work well with others and contribute to the overall positive work environment of both the Department and the Company
    • Demonstrates high reliability through consistent punctuality and attendance
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Minimum 2 years' experience as a "Medical Claims Auditor" is required.
  • Experience working with Medicare / Medicaid / Managed Care claims
  • Experience working with Provider Disputes and Appeals
  • Knowledge of healthcare regulations and guidelines including
    • CMS
    • DMHC
    • DHS guidelines
  • Intermediate proficiency with Excel


Preferred Qualifications:
  • Associates Degree (AA) or 2-3 years related experience and/or training; or equivalent combination of education and experience.
  • Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms and CPT Coding.


Careers with Optum . Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)

AppleCare Medical Group was formed in Lynwood, California in 1996 with the goal of making quality care available locally to the community. Today, AppleCare Medical Group is comprised of hundreds of board-certified private-practice, independent physicians. These physicians provide medical expertise and passion to improving the health of communities in the Southeast area of Los Angeles and Northern Orange County.

AppleCare Medical Management Group was incorporated in 2003. Over the last 17 years, the multispecialty medical group of independent practices has expanded into new communities, contracted with more hospitals and health plans, and added over 50 new doctors - but the mission has remained the same. Today, AppleCare Medical Management is comprised of hundreds of board-certified private-practice, independent physicians. Collectively, our physicians have been serving the Southeast area of Los Angeles and Northern Orange County for decades, providing their medical expertise and passion to improving the health of our communities.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: Healthcare Claims Auditor, La Palma, CA, California

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