Initiate and expand recovery opportunities through provided audit results, Provider calls, Third Party Liability and CCS eligible services.
Audit payment errors that result in Provider refund checks to properly apply funds and determine the root cause.
Communicate with and answer Provider inquiries and/or Provider Disputes regarding the reason for the refund request based upon claims processing guidelines, contractual agreements involving the use of established payment methodologies, Division of Financial Responsibility, and regulatory guidelines.
Promote teamwork and maintain effective working relationships with others throughout the organization.
Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Minimum of four (4) years of claims processing experience including Medicare and Medi-Cal
Two (2) years of experience auditing claims in a managed care environment including contract and financial DOFR interpretation
Experience with MS Office applications
High School Diploma or GED required
Bachelor’s degree from an accredited institution preferred
Knowledge of Medi-Cal and CMS guidelines for claim payments
Strong analytical and problem-solving skills
Proficient in Microsoft Office, including being able to manipulate large data sets in Excel files
Excellent oral and written communication skills
Ability to build successful relationships across the organization

Auditor – Provider Recovery

Key skills