Managed Care Claims Auditor

Position Summary

We are seeking a detail-oriented and analytical Auditor to join our team, with a focus on reviewing managed care claims to ensure billing accuracy, compliance with payer contracts, and identification of fraud, waste, or abuse. This role involves deep dives into claims data, provider billing patterns, and contract terms to identify discrepancies and recommend corrective actions.

Duties

• Conduct audits of managed care claims to verify accuracy, appropriateness, and adherence to contractual and regulatory requirements.
• Identify billing anomalies, upcoding, unbundling, duplicate billing, or other indicators of fraud, waste, or abuse.
• Analyze claim data using audit software and data analytics tools (e.g., Excel, SAS, SQL, Power BI).
• Review and interpret managed care contracts, payer policies, fee schedules, and medical records as needed to support audit findings.
• Prepare detailed reports with findings, supporting documentation, financial impact, and recommended corrective actions.
• Collaborate with internal departments (billing, coding, compliance, legal) and external stakeholders (payers, providers) to resolve discrepancies.
• Stay current with industry regulations, CMS guidelines, and payer-specific billing requirements.
• Support investigations of potential fraud or overpayment recovery efforts.
• Assist in the development of audit methodologies, risk assessments, and process improvement initiatives.
  
  

Job Qualifications

Minimum Education (Indicate minimum education or degree required.)

• Bachelor's degree in Accounting, Finance, Healthcare Administration, or related field.
  
  

Preferred Education (Indicate Preferred Education Or Degree Required.)

• N/A
  
  

Minimum Work Experience and Qualifications (Indicate minimum years of job experience, skills or abilities required for the job.)

• Minimum of 5 years of experience in forensic auditing, healthcare claims auditing, or managed care analytics.
• Strong working knowledge of managed care claims processing, CPT/HCPCS/ICD-10 coding, and payer reimbursement methodologies.
• Familiarity with MediCal, Medicare, and commercial insurance guidelines.
• Proficient in data analysis tools (e.g., Excel, Access, SQL, audit software).
• Exceptional attention to detail and analytical thinking.
• Strong written and verbal communication skills, with the ability to present findings to both technical and non-technical audiences.
• Ability to manage multiple priorities in a deadline-driven environment.
  
  

Preferred Work Experience and Qualifications (Indicate preferred years of job experience, skills or abilities required for the job.)

• Certified Fraud Examiner (CFE), Certified Internal Auditor (CIA), or similar certification.
• Prior experience at a Management Service Organization (MSO) of Health plan a plus
• Experience working with healthcare auditing platforms or tools (e.g., Truven, Minitab, RAC tools).
• Background in healthcare compliance or legal investigations related to claims a plus.
  
  

Required Licensure, Certification, Registration or Designation (List any licensure or certification required and specify name of agency.)

• Current Los Angeles County Fire Card (or must be obtained within 30 days of hire)
• Assault Response Competency (ARC) required (within 30 days of hire)
  
  

Full-Time, Exempt