The Claims Auditor is responsible for working with the Managed Care Compliance Manager to ensure compliance with applicable rules and regulations including but not limited to AB1455 and Medicare Claims Processing Guidelines. Responsible for maintaining routine auditing functions and providing feedback on departmental activities to ensure ongoing compliance with all health plan and regulatory agencies, including CMS, DMHC, and DHCS.
Job Duties and Responsibilities:
Evaluates claims adjudication using standard principles and state specific policies and regulations in order to ensure accurate and timely claims adjudication
Performs moderately sophisticated claim audits on a routine basis for payment accuracy by following regulatory standards, and business policies
Assist manager with validation of health plan findings
Conducts quality assurance audits for claim adjustments, refunds and provider disputes
Performs focused reviews and provides reports to the Compliance team
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major t...eaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.