CEN-California State Prison, Centinela
CEN-California State Prison, Centinela
SVSP-Salinas Valley State Prison
SVSP-Salinas Valley State Prison
CMF-California Medical Facility
BRO-Bakersfield Regional Office
SVSP-Salinas Valley State Prison
CMF-California Medical Facility
BRO-Bakersfield Regional Office
CHCF-California Health Care Facility
HDSP-High Desert State Prison
SAC-California State Prison, Sacramento
San Quentin, California
Crescent City, California
San Luis Obispo, California
Posted: 26-Apr-25
Location: Los Angeles, California
Internal Number: 147253925
Take on a key role within a world-class, award-winning health system. Ensure the efficient delivery of award-winning patient care. Take your career in an exciting new direction. You can do all this and more at UCLA Health.
The Claims Quality Auditor serves as the primary point of contact for submission and resolution of Provider Dispute Resolutions and Appeals. They will assess and complete appropriate documentation for tracking PDR/Appeals data and conduct all pertinent research to evaluate, respond and close incoming Appeals from providers and other entities accurately, timely and in accordance with all established regulatory guidelines. The incumbent will prepare and assists with reports for the department. Additional responsibilities include:
- Reviewing claims for accuracy, appropriate application of benefits, contract interpretation and compliant with policies and procedures
- Compile and maintain statistical data consistent with department guidelines and consistently maintain production and quality standards in accordance with department policy
- Additional responsibilities may be included based on department needs
- High school diploma, GED or equivalent experience required
- Minimum of 4 years medical claims payment experience in an HMO environment (i.e. MSO, IPA or health plan) required
- Experience with CPT-4, ICD-9CM, RBRVS, ASA and HCPCS as well as an understanding of Medicare Guidelines and COB required
- Demonstrated medical terminology competence.
- Working knowledge and experience in benefit determination, claims adjudication, policies and procedures and processes.
- Must be able to type 40 - 50 WPM with high accuracy for alpha and numeric data inputting
- Extensive working knowledge of professional and facility reimbursement methodologies.
- Must be detailed oriented, attentive, organized, and able to follow directions.
- Ability to work independently utilizing company established processes.
- Ability to meet deadlines and maintain department quality standards.
- Intermediate computer skills including Microsoft Word and Excel.
- Good working knowledge of claims adjudication systems.
