Claims Compliance Auditor

Overview:

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

As a Claims Compliance Auditor, you will play a critical role in safeguarding the financial integrity and regulatory compliance of Inland Empire Health Plan’s claims payment system and processes.  Your attention to detail, analytical skills, and commitment to excellence will ensure the accuracy, compliance, and efficiency of claims processing within the organization. By meticulously reviewing claims data, policies, and procedures to identify discrepancies, errors, and potential areas for improvement you will be ensuring that IEHP’s providers receive accurate reimbursement for services, rendered, ultimately contributing to the delivery of high-quality healthcare services to our members. 

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members; we also aim to match our Team Members with the same energy by providing prime benefits and more.

• CalPERS retirement
• 457(b) option with a contribution match
• Generous paid time off- vacation, holidays, sick
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Paid life insurance for employees with additional options
• Short-term, and long-term disability options
• Pet care insurance
• Flexible Spending Account – Health Care/Childcare
• Wellness programs that promote a healthy work-life balance
• Career advancement opportunities and professional development
• Competitive salary with annual merit increase
• Team bonus opportunities

1. Claims Auditing: Conduct thorough and systematic review of healthcare claims to ensure adherence to contractual agreements, regulatory guidelines, and internal policies. 
2. Data Analysis: Analyze claims data to ensure the quality and accuracy of claims submissions, including coding and billing, in order to identify trends of payment inaccuracies and over-utilization patterns.  Provide insights and recommendations to enhance efficiency and accuracy in claims processing.  
3. Compliance Monitoring: Stay abreast of evolving healthcare regulations, reimbursement policies, and coding guidelines to ensure compliance and mitigate the risk of fraud, waste, and abuse.  
4. Fraud Detection: Utilize analytical skills and industry knowledge to detect patterns or inconsistencies indicative of fraudulent activities. Promptly report suspected fraud cases to the designated department for further investigation.  
5. Communication: Collaborate with multiple business units to resolve discrepancies and address issues identified during the auditing process. Communicate audit findings clearly and professionally, both verbally and in written reports.  
6. Process Improvement: Identify opportunities to streamline claims processing workflows, enhance system functionality, and optimize reimbursement accuracy, proposing and implementing innovative solutions as needed.  

Education & Experience

• Four (4) years auditing experience in a managed care environment with an emphasis in claims auditing
• Experience with contract and Division of Financial Responsibility (DOFR) interpretation
• Previous experience in claims processing including Medi-Cal and Medicare
• Two (2) years analyzing data using Microsoft Excel
• High school diploma or GED required
• Must have a valid California Driver's License

Key Qualifications

• Strong knowledge of healthcare reimbursement methodologies, coding systems (e.g., CPT, ICD-10), and regulatory compliance requirements (e.g., HIPAA, CMS, DHCS, DMHC).
• Skilled in auditing, interpreting complex claims data, and identifying claims processing trends.  Excellent analytical and problem-solving skills.  Excellent communication skills, both verbal and written.   

Start your journey towards a thriving future with IEHP and apply TODAY!

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