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Senior Manager, Claims Audit - Full Time, Days (Orange, Ca) at Prospect Medical Systems - CA in Orange, California

Posted in General Business 30+ days ago.

Type: Full-Time

Job Description:

Senior Manager, Claims Audit - Full Time, Days (Orange, Ca)

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

Claims Quality Audit Sr. Manager is responsible for the development and execution of Claims Quality Audit Operations strategies, overall Audit program, end-to-end Claims Testing, Audit and Testing process optimization and management, identifying and leveraging technology and data to improve the quality and minimize process cost of Claims. This position will own the overall Claims Audit and Testing roadmap to ensure that the Claims Administrations is adhering to regulatory and internal guidelines as they apply to claims processing and adjudication. The Sr. Manager will collaborate with other Prospect departments and personnel to develop strategies to identify, mitigate and optimize operational and financial gaps.

Job Responsibilities/Duties

  • End-to-End Claims Audit & Testing Strategy Development & Execution
  • Responsible for working with IT, Configuration, Claims Operations and PDR teams, and other departments to create and maintain an end-to-end testing and audit strategy for Claims Administration
  • Ensures the Audit plan covers all aspects of claims adjudication, including but not limited to meeting compliance with managed care governing entity requirements such as CMS, DMHC, different contracted IPAs and Medical Groups, DOFR and Provider Contract change validation, etc.
  • Ensures adherence to the daily and scheduled focused audit plan. Responsible for working with IT, Configuration, Claims Operations and PDR teams and other departments to develop and orchestrate applicable corrective action plans with a feedback loop to Claims Operations/ Configuration/ IT Ops to ensure deficiencies do not reoccur
  • Assists in the development of tools and technologies to effectively maintain, update, or revise all audit and testing tools, scorecards, dashboard, and reporting templates, as necessary.
  • Utilize tools and technologies effectively to develop, maintain, update, or revise all audit and testing tools, scorecards, dashboard, and reporting templates, as necessary.
  • Ensures clear metrics are defined, measured and reported for tracking and trending Claims testing and audit outcomes
  • Actively engages in Root Cause analysis of deficiencies, and lead efforts in development and implementation of effective remediation and process improvement solutions.
  • Proactively identifies focus areas for audits based on trends/data and inputs from external audits and makes required adjustments
  • Collaboration & Partnership
  • Builds and maintains productive & collaborative intradepartmental relationships with department leads (IT, Claims Operations & PDR, Configuration, Contracting, Medical Management, etc.) to enable effective and timely problem/improvement identification & resolution. Acts as a resource to department management for brainstorming audit and testing ideas/solutions.
  • Works with the Claim Operations team and Configuration team to develop and implement audit processes in order to comply with Medicaid (including Medi-Cal) and Medicare processing guidelines
  • Works in close partnership and collaboration with the Claims Operations and PDR teams, Configuration team, Contracting Team and IT team to identify areas of opportunities and/or issues and risks based on internal audit findings
  • Coaching, Mentoring, Managing & Overseeing a team of Auditors
  • Responsible for the overall monitoring of production volume, quality, and turnaround time; establish appropriate and effective production goals and quality benchmarks for the team
  • Conducts regular, ongoing review and analysis of all Claims Auditors and Quality Assurance Analysts to ensure audit quality and accuracy
  • Identifies any new learning opportunities for staff (Standard operating Procedures. Desktop Procedures, Policies and Procedures, etc.) and conducts/manages focused audits as requested
  • Collaborates with internal staff to develop and implement processes, policies and procedures and other activities to ensure State and Federal standards and requirements are followed
  • Adjusts and aligns audit tactics to quickly respond to changing priorities and business needs; ensures flexibility of the department through effective communication of business rationale.
  • Monitors and communicates performance goals and results to staff, engaging in appropriate coaching and development opportunities, and improvement action plans as needed.
  • Develops and maintains an environment that encourages teamwork and communication and supports quality and process improvement suggestions and solutions


Minimum Education: Bachelor's degree or equivalent experience preferred with healthcare administration focus.

Minimum Experience: Six to eight (6-8) years claims administration experience in a Health Plan/IPA/MSO setting. Three plus (3+) years of experience in a supervisory capacity required. Experience and knowledge of professional and institutional claims processing, health plans contract interpretation and understanding of the Division of Financial Responsibility (DOFR) and benefit plans. Experience with interpretation of contracts or LOA's, DOFR's, monitoring, and enforcing contract provisions, payment rates, and quality management required. IDX experience preferred. Core System implementation experience. Core System configuration experience preferred.

Req. Certification/Licensure: None.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol. Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm. For this reason, we require applicants to pass a screening for drug use as a condition of employment. This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.

How to Apply

To apply for this role, or search our other openings, please visit and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law:

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