Claims Auditor (Onsite)
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Job Location:
Whittier, CA - USA
Monthly Salary:
USD 21 - 35
Posted on:
16-10-2025
Vacancies:
1 Vacancy
Job Summary
The Claims Quality Assurance Auditormaintains positive working relationships with our internal and external customers health plans providers and/or members by seeking a partnership approach that will meet the company goals and vision. The CQA auditor will coordinate Health Plans audits activities with preparation and provide preliminary results on non-compliant issues to CQA manager. Oversees audit findings and provide education to claims staff and other internal customers within PIH. Assists with developing an audit control checklist for prevention of claims timeliness payment accuracy systematic or statistical errors in PIH managed care claims system. Develop a root cause analysis report for common trends to provide feedback to the claims staff/ team and/or PIH internal customers. Oversees in conjunction with the Managed Care Management Team to ensure QA programs are aligned with claims operations and other areas that have direct impact with claims to prevent non-compliance. Adheres to internal department standard operating procedures and applies standard industry guidelines in accordance with regulatory agencies (state and federal). Researches analyzes and resolves complex problems dealing with claims audits including member denials provider disputes deficiencies that will potentially jeopardize the claims department. Has extensive knowledge of current and future claims processing audits compliance adjustment provider disputes DOFRs and/or configuration etc.
PIH Health is a nonprofit regional healthcare network that serves approximately 3 million residents in the Los Angeles County Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital PIH Health Good Samaritan Hospital PIH Health Whittier Hospital 37 outpatient medical office buildings a multispecialty medical (physician) group home healthcare services and hospice care as well as heart cancer digestive health orthopedics womens health urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nations top hospital systems for best practices cutting-edge advancements quality of care and healthcare technology. For more information visit or follow us on Facebook Twitter or Instagram.
Required Skills
- Computer system skills/knowledge (MS Excel and Word)
- Written and verbal communication skills
- Managed Care Knowledge and confidence exposure and expected
- Knowledge of claims processing CPT/RBRVS/ICD codes
- Level of comprehension as it relations to regulatory compliance and guidelines associated with the following: CMS DMHC DOI DHS etc.
- Analyze data understanding the trends
- Identifies compliance gaps in processes and systems by providing a risk based solution for prevention
- Prepares issues and tracks deficiencies noted during claims pre/post audit and inspection
- Extensive knowledge on root cause analysis/trends
- Organizational skills
- Ability to work independently with minimum supervision
- Meet deadlines and completion on assigned projects in a timely manner
- Ability to take initiative in analyzing problems developing a solution with a win-win approach
- Confidentiality and Honesty with compliance
- Great customer service skills with internal and external customers
- Communicate with CQA manager
Key Skills
- Auditing
- Time Management
- ICD-10
- Accounting
- Component evaluation
- Workers' Compensation Law
- SOX
- Microsoft Excel
- CPT Coding
- Internal Audits
- Medicare
- Bookkeeping
