Claims Auditor

Claims Auditor The Claims Auditor plays a crucial role in the Claims Department by analyzing procedures, policies, and reports to ensure the appropriate resolution of claims and the maintenance of the claims system. This role involves coordinating the generation and review of claims reports and ensuring compliance with company guidelines. Responsibilities: Assist the Claims Director in training and educating the Claims department staff. Coordinate the generation and review of claims audit, status, and pending claims reports, ensuring authorized claims are paid in accordance with company guidelines. Investigate, process, and track resolution adjustments including refunds, overpayments, and underpayments. Act as a resource for providers, members, insurance carriers, attorneys, and co-workers, researching and responding to questions promptly. Create, maintain, and generate system reports. Interface with the Claims Director to ensure claims processing functions meet legal and contractual requirements regarding health plan audits. Prepare and present weekly and monthly reports reflecting staff and departmental quality statistics. Review and audit member liability denials and Provider Dispute Resolution claims to ensure compliance with regulatory requirements and passing audit scores from health plans. Essential Skills: Compliance Claims management Claims analysis Knowledge of DOFR Lab Claims Familiarity with UB-92 and HCFA-1500 Additional Skills & Qualifications: Knowledge of HMO/IPA operations and medical terminology. Understanding of ICD-10, RVS, and CPT coding. Knowledge of Medicare and Medi-Cal guidelines. Proficiency in 10-key skills by touch. Excellent communication skills. Knowledge of system applications. Ability to function effectively under time deadlines. Strong organizational skills. Bilingual skills in Spanish/Chinese preferred. Work Environment: The work schedule is Monday through Friday, from 07:00 am to 03:30 pm. Please note that orientation times may differ from the shift times listed. The work environment supports a collaborative and efficient atmosphere, aiming to maintain the highest standards of claims auditing. Job Type & Location: This is a Contract position based out of Whittier, CA. Pay and Benefits: The pay range for this position is $21.00 - $28.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: Medical, dental & vision Critical Illness, Accident, and Hospital 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available Life Insurance (Voluntary Life & AD&D for the employee and dependents) Short and long-term disability Health Spending Account (HSA) Transportation benefits Employee Assistance Program Time Off/Leave (PTO, Vacation or Sick Leave) Workplace Type: This is a fully onsite position in Whittier, CA. Application Deadline: This position is anticipated to close on Mar 12, 2026.

Created: 2026-03-05