- Conducts quality assurance audits for all Lines of Business.
- Conducts quality assurance audits for claim adjustments, refunds and provider disputes.
- Performs routine and moderately complex claim audits for payment accuracy in accordance with regulatory standards, and business policies.
- Participates in some special projects/work.
- Participates in the appropriate and approved training classes during year (in accordance with goals).
- Demonstrates awareness of work required at next level and working at that standard.
- Works on problems of moderate scope where analysis of situations and / or data requires review of variety of factors.
- Exercises good judgment within defined procedures and practices to determine appropriate action.
- Builds productive working relationships internally and externally.
- Presents ideas assertively and directly, providing data to support conclusions.
- Adapts ideas and ties them to the needs and goals of others to gain their support and commitment.
- Applies knowledge of internal and external regulatory processing guidelines.
- Requires a minimum of three (3) years of claims processing experience OR two (2) years medical claims auditing experience.
- Associates degree or two (2) years of directly related experience.
- High School diploma or General Educational Development (GED) required.
- N/A
- Must be able to work in a Labor-Management Partnership environment.
- Certification in medical terminology from an acceptable entity is preferred.
- Intermediate competency in MS Office Applications (Excel and Word).
- Strong ability with proprietary and mainframe processing systems KP technologies (e.g., Tapestry) is preferred.
- Internal candidates should meet or exceed performance metrics for 5 or more consecutive quarters.
- Able to discuss mission, vision and objectives within own department and unit.
- Describes company philosophy, culture and history.
- Discusses the roles and responsibilities of major business units and departments operating principles and practices.
- Able to identify and discuss key players, key issues and strategies.
- Understands and Interprets contracts and DLPs/P&Ps, knowledgeable with CPT coding, ICD-10, HCPCS coding, various pricing methodologies and benefit application.
- Possesses a good understanding of healthcare benefits and health care delivery from either/both a payor or provider perspective, EDI and paper claim lifecycle.
- Listens actively and demonstrates sensitivity to staff members/customers, encouraging them to discuss concerns, interests, needs and difficult issues.
- Works effectively in teams to achieve common goals.
- Monitors own work and seeks further experiences to ensure continual quality patient/customer service delivery.
- Identifies and discusses client expectations as relevant to own area.
- Monitors and reports on delivery of what was promised.
- Conducts and analyzes daily problems for trends and take steps to avoid recurrence.
- Puts forward ideas assertively and directly, providing data to support conclusions.
- Adapts ideas and ties them to the needs and goals of others to gain their support and commitment. Clearly communicates using verbal and written methods.
- Four (4) years of claims processing experience preferred.
-
Intermediate Medical Claims Quality Auditor Ii
2 weeks ago
Kaiser Permanente Downey, United States**Job Summary**: · Remote from any KP location in CA, OR, CO, WA, GA, MD, VA, HI or D.C. Only. · Quality Claims Auditor: This position exists to ensure the integrity of medical payments for the organization through verification of the accuracy of data-entered information and by a ...
-
Quality Control Auditor
1 week ago
humano Ontario, United States**Job Summary**: · **Qualifications**: · - Proven experience in quality control, auditing or selecting in a warehouse **(There will be a skills test given)**: · - Strong attention to detail · - Excellent communication and reporting abilities · - Ability to work independently and ...
-
Intermediate Quality Auditor II
1 week ago
Kaiser Permanente Downey, United StatesJob Summary: · Remote from any KP location in CA, OR, CO, WA, GA, MD, VA, HI or D.C. Only. · ** PLEASE NOTE: Salary ranges are geographically based and the posted range reflects the Southern CA region. Applicable salary ranges will apply for other labor markets outside of SCAL. ...
-
Quality Auditor
1 week ago
SQA Services Los Angeles, United StatesSQA is a leading Quality Assurance and Supply Chain solutions firm. SQA manages Supplier Audit and Supplier Development programs for clients in quality-critical industries, including Pharmaceutical, Medical Device, Automotive, Aerospace, and Electronics manufacturing. Clients lev ...
-
Quality Auditor
3 weeks ago
AFL Los Angeles, United StatesThe Quality Auditor will be responsible for attending/auditing telecommunication sites (Central Office) where they will ensure completed builds (both upgrades and new installations, active and passive elements) have been installed/constructed in accordance with the site design an ...
-
Quality Auditor
3 weeks ago
Skyryse El Segundo, United StatesSkyryse wants to empower anyone, to fly anywhere, in any aircraft, safely and as a highly experienced pilot would. Powered by SkyOS, we automate flight controls and systems management to achieve unmatched safety and eliminate opportunities for human error. We want to make flying ...
-
Quality Auditor
15 hours ago
HydraFacial Long Beach, United States Full timeDescription · : Hydrafacial, a leading medical device company, seeks a detail-oriented and experienced Auditor to join our Quality Assurance team. The ideal candidate will be responsible for conducting internal audits, preparing for external audits, and auditing suppliers to ens ...
-
Kaiser Permanente Downey, United StatesJob Summary: · Remote from any KP location in CA, OR, CO, WA, GA, MD, VA, HI or D.C. Only. · ** PLEASE NOTE: Salary ranges are geographically based and the posted range reflects the Southern CA region. Applicable salary ranges will apply for other labor markets outside of SCAL. ...
-
Kaiser Permanente Downey, United StatesJob Summary: · Remote from any KP location in CA, OR, CO, WA, GA, MD, VA, HI or D.C. Only. · ** PLEASE NOTE: Salary ranges are geographically based and the posted range reflects the Southern CA region. Applicable salary ranges will apply for other labor markets outside of SCAL. ...
-
Intermediate Medical Claims Quality Auditor II
2 weeks ago
Kaiser Permanente Downey, United States: Job Summary: · Remote from any KP location in CA, OR, CO, WA, GA, MD, VA, HI or D.C. Only. · ** PLEASE NOTE: Salary ranges are geographically based and the posted range reflects the Southern CA region. Applicable salary ranges will apply for other labor markets outside of SCA ...
-
Quality Auditor
3 weeks ago
Skyryse El Segundo, United States Full timeABOUT SKYRYSE: · Skyryse wants to empower anyone, to fly anywhere, in any aircraft, safely and as a highly experienced pilot would. Powered by SkyOS, we automate flight controls and systems management to achieve unmatched safety and eliminate opportunities for human error. We wan ...
-
Claims Quality Auditor
3 weeks ago
University of California Los Angeles, United StatesTake on an important role within a world-class health organization. Provide specialized expertise that enables the efficient operation of a complex health system. Take your career to the next level. You can do all this and more at UCLA Health. · The Claims Quality Auditor will be ...
-
Claims Quality Auditor
3 weeks ago
UCLA Health Los Angeles, United StatesGeneral Information · Press space or enter keys to toggle section visibility · Work Location: Los Angeles, USA · Onsite or Remote · Flexible Hybrid · Work Schedule · Monday - Friday, 7:00am - 3:30pm PST · Posted Date · 01/30/2024 · Salary Range: $ Hourly · Employment Ty ...
-
Claims Quality Auditor
4 days ago
UCLA Health Los Angeles, United StatesGeneral Information · Press space or enter keys to toggle section visibility · Work Location: Los Angeles, USA · Onsite or Remote · Flexible Hybrid · Work Schedule · Monday - Friday, 7:00am - 3:30pm PST · Posted Date · 01/30/2024 · Salary Range: $ Hourly · Employment Type · 2 - S ...
-
Quality Assurance Auditor
1 week ago
Patco Brands Los Angeles, United StatesPatco Brands is one of the fastest growing beverage companies in the United States. Independently owned, Patco has established itself by using 100% Blue Weber Agave and a proprietary process to innovate within the fast growing ready-to-drink spirits category. · Patco is a maker ...
-
Quality Assurance Auditor
1 week ago
24 Seven Talent Los Angeles, United StatesOur beverage client is looking to bring on a Quality Assurance Auditor to their team on a fulltime basis, sitting in California or on the West Coast as this role will require travel. · Responsibilities: · Travel to all production and co-manufacturing facilities on a regular basi ...
-
Quality Assurance Auditor
1 week ago
Patco Brands Los Angeles, United StatesPatco Brands is one of the fastest growing beverage companies in the United States. Independently owned, Patco has established itself by using 100% Blue Weber Agave and a proprietary process to innovate within the fast growing ready-to-drink spirits category. · Patco is a maker ...
-
Quality Assurance Auditor
1 week ago
Altasciences Cypress, United StatesYour New Company · At Altasciences we all · move in unison to assist and work in the discovery, development, and manufacturing of new drug therapies to get them faster to people who need them.No matter your role, we all play an important part and you will have a significant imp ...
-
Quality Assurance Auditor
1 week ago
24 Seven Talent Los Angeles, United StatesOur beverage client is looking to bring on a Quality Assurance Auditor to their team on a fulltime basis, sitting in California or on the West Coast as this role will require travel. · Responsibilities: · Travel to all production and co-manufacturing facilities on a regular bas ...
-
Quality Assurance Auditor
1 week ago
Altasciences Cypress, United StatesYour New Company · At Altasciences we all · move in unison to assist and work in the discovery, development, and manufacturing of new drug therapies to get them faster to people who need them.No matter your role, we all play an important part and you will have a significant impa ...
Intermediate Medical Claims Quality Auditor II - Downey, United States - Kaiser Permanente
Description
Job Summary:Remote from any KP location in CA, OR, CO, WA, GA, MD, VA, HI or D.C. Only.
** PLEASE NOTE: Salary ranges are geographically based and the posted range reflects the Southern CA region. Applicable salary ranges will apply for other labor markets outside of SCAL.
Quality Claims Auditor: This position exists to ensure the integrity of medical payments for the organization through verification of the accuracy of data-entered information and by auditing service related information and invoice adjudication/payment for compliance with contract terms and Department/Regional policy and procedures.
The auditor must be proficient with the medical systems, claims processing and adjudication. The position requires research, problem resolution and specialized knowledge in the areas of benefits, contracts, Medicare, Medicaid, Coordination of Benefits and Third-Party liability, WebStrat, Multiplan, Beechstreet and other pricers.
