Providence Mission Hills Jobs

Job Information

Providence Claims Quality Assurance Auditor in Mission Hills, California


Providence is calling a Claims Quality Assurance Auditor (Full time/Day shift) to Providence Facey Medical Foundation in Mission Hills, CA.

We are seeking a Claims Quality Assurance Auditor who will manage the claims internal audit functions, which includes audit process for adjudicated claims and encounters. Monitor check run process for accuracy. Develop policies and procedures for periodic claims audits and ensure compliance with affiliated health plans, client groups, and administrative contractual agreements. Designs, plans, directs and implements claims training programs for the organization, to include adaptations to changes in policies, procedures and technologies. Must be familiar with applicable State and Federal claim payment and denial timeliness legislation. Must be familiar with Timeliness Compliance pursuant to State and Federal rules and regulations. Must be well versed regarding the Provider Dispute Resolution tracking mechanism (AB1455). Responsible for ensuring customer (provider-vendor) satisfaction while maintaining the integrity of Facey's vision and business objectives. Demonstrates a high level of integrity and innovative thinking and actively contributes to the success of the Team. Supports, encourages and models attitudes, actions and behaviors that will make Facey the best in the industry in customer measured quality and responsiveness requirements. Serves as a liaison between contracted health plans, patients, hospitals and the Information Technology Dept. at Facey. Provides day-to-day assistance and training on Claims compliance matters to the Claims Examiners and Adjudication teams.

In this position you will:

  • Delivers upon the service expectations of both our patients and fellow staff members by listening to their needs; engaging in positive interactions; and following through on promises made in a thoughtful, efficient, timely and courteous manner so that their total outcome is better than expected

  • Respect the dignity, confidentiality and privacy of patients

  • Work in a safe manner, adhering to general safety precautions and standards Report any unsafe conditions to their supervisor and/or the safety hotline

  • Monitor the printing of denial letters, separate, file and mail letters

  • Perform random audits of data entered and processed batches for accuracy

  • Review additional information, and pend letters for accuracy

  • Participate in meetings regarding the claim audit function, in order to improve the process and resolutions

  • Assist manager with compiling and analyzing the supporting documentation for monthly and quarterly timeliness and interest reports

  • Motivate team members to produce quality outcomes within expected time frames

  • Review PDRs for determination and process AB1455 Appeals according to PDR procedures

  • Ensure Facey maintains, a log of all Provider Dispute Resolutions (PDR), and send acknowledgment letters timely, according to AB-1455 regulations

  • Ensure all policies and procedures created to support AB-1455, specifically relating to PDRs are current and accurate based on the ICE interpretation

  • Respond to complex, or non-routine written inquires received from Provider Vendors, Hospitals and Members

  • Participate in meetings and task forces relating to tactical planning or implementation as appropriate

  • Analyze and trend monthly team quality/production standards and statistical reports, provides feedback and make recommendation to manager and/or director

  • Accountable for daily reporting routines and support of department goals

  • Assure a continuously improving workflow process, identifies needs, make recommendations and implements changes

  • Audit and report individual and team quality/production performance; gives daily, weekly and monthly feedback to staff. Identify performance trends and discusses trends with Supervisor

  • Coordinate and or conduct on-the-job-training. Creates job aids and forms

  • Review cases involving overpaid claims and initiate appropriate collection or expense recovery action in accordance with established policies and procedures

  • Act as a resource to Claims Processors regarding interpretation of Health Plan division of financial responsibility

  • Act as a resource to IT Dept. for testing for new contracts loaded to the system as well as all maintenance processes that involved MCA (Managed Care Claims System of IDX) Identify third party liability claims and notify supervisor

  • Interact with the IT Dept. to ensure that contract rates are loaded and applied correctly to every claim payment situation

  • Interact with the Utilization Review Department ensuring that UR Authorization practices are operational to both UR and Claims Depts

  • Manage and handle special projects delegated by Supervisor or Senior Management


Required qualifications for this position include:

  • Bachelor's Degree Or equivalent educ/experience

  • 10 or more years HMO claims processing experience in a managed care environment, preferably PMG/IPA setting within the last 7 years or any combination of education and/or experience which produces an equivalency

  • Comprehensive knowledge on claims reimbursement methodologies, data elements and coding

  • Strong knowledge of HMO membership, plan benefits, plan designs and health plans protocols on enrollment in a managed care environment

  • Extensive knowledge of medical terminology, HMO claims processing guidelines including EDI Claims, and government claim processing regulations

  • Knowledge of AB 1455 Provider Dispute Resolution Mechanism and its application according ICE guidelines

  • Proficient with producing reports via Access and Excel, data analysis and ability make mathematical calculations

  • Must possess excellent oral and written communication skills and computer skills

  • Proficient use of Microsoft Word, Excel, Access, Outlook, and PowerPoint a must

  • Must display a high level of flexibility and attention to detail

  • Must possess excellent customer service and communication skills, be organized and a self-starter

About the organization you will serve:

Facey Medical Group is a multi-specialty medical group with over 160 physicians providing care to the growing population in the North & East regions of Los Angeles & Ventura Counties. Twelve medical clinics, including two urgent care centers and dedicated women's centers, are located across the San Fernando, Santa Clarita and Simi Valleys. The group began as a single medical practice over 90 years ago.

Facey is part of Providence Health & Services, an integrated, not-for-profit 5-state network of hospitals, care centers, medical clinics, affiliated services and educational facilities spanning from California to Alaska.

For information on our comprehensive range of benefits, visit:

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: Full-time

Shift: Day

Job Category: Claims

Location: California-Mission Hills

Req ID: 267158