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Managed Care Claims Auditor
at agilon health
Anaheim, CA

Managed Care Claims Auditor
at agilon health
Anaheim, CA

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Job Description


Position Summary:

The Claims Auditor performs various audits of claims denials, payments, pre and post check, targeted audits, focused audits, health plan readiness audits, and denials to ensure payment accuracy and integrity based on industry standards, the DOFR agreements and federal/state regulatory requirements.

Essential Job Functions:

  • Conducts pre- and post-payment audits to ensure accurate claims payments and denials
  • Utilizes knowledge of DOFR (Division of Financial Responsibility) and Medicare/Medi-Cal, and Commercial requirements to conduct thorough reviews of all parts of the claims process.
  • Gathers relevant audit data, prepares audit reports, and makes recommendations for process improvements based on audit findings.
  • Strong knowledge of claims processing standards to ensure regulatory compliance and to improve overall quality and efficiency.
  • Identifies and appropriately escalates any audit-related problems to immediate supervisor.
  • Supports and facilitates external audits and projects as directed.
  • Contributes to team effort by accomplishing related results based on performance metrics as needed.
  • Recommends training needs based on error patterns.

Other Job Functions:

Meet and maintain established quality and production standards for auditing claims.

  • Work independently and as part of a team.
  • Develop and maintain effective working relationships with all levels of staff and providers.
  • Handle multiple tasks and meet deadlines.
  • Effectively utilize computer and appropriate software and interact as needed with agilon health Claims Processing Systems.

Required Qualifications:

Minimum Experience

  • High school graduate or equivalent. High School diploma
  • 3+ years claims processing experience in a managed care environment.
  • 1-3 years Claims Audit experience preferred.
  • Experience processing Medicare, Medi-Cal and Commercial claims preferred.
  • Must have good customer service skills.
  • Strong oral and written communication skills.

Company Description

The passion to change the way healthcare is delivered permeates everyone and everything at agilon health. Working together we can use our expertise to make a difference in the lives of patients and physicians alike. We can bring the joy back to practicing medicine for physicians and improve the care experience for patients across the country.

We believe that every member of our team plays a critical role in transforming care for our patients. Our customer service teams are the front line for physicians and patients navigating the system and, without our claims processing departments, our health plan partners and provider networks couldn’t do their jobs. No matter what your role is at agilon health, you can and will make a difference in the lives of the seniors and Medicaid populations we serve. Our culture and passion has already been embraced by nearly 500 employees in three states. And we are excited to welcome new members to the team as more physicians and patients experience the difference agilon health can make.

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