Quality Control Auditor

Description

JOB SUMMARY

The Quality Control Auditor – Claims Management is responsible for performing detailed audits of claims processing activities to ensure accuracy, regulatory compliance, and adherence to contractual, coding, and reimbursement requirements within the Managed Services Organization (MSO). This role evaluates claims adjudication performed by Claims Examiners, identifies errors, analyzes trends, and provides recommendations to improve claims accuracy, operational efficiency, and compliance with federal and California regulatory standards.

The Quality Control Auditor supports delegated managed care compliance by auditing claims in accordance with health plan contracts, coding standards, reimbursement methodologies, and applicable regulatory requirements, including Department of Managed Health Care (DMHC), Centers for Medicare & Medicaid Services (CMS), and Department of Health Care Services (DHCS) standards where applicable.

This role plays a critical role in maintaining claims processing integrity, minimizing financial risk, ensuring regulatory compliance, and supporting continuous operational improvement.

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education/Training

Minimum: High School Diploma or equivalent.

Preferred: Associate’s or Bachelor’s degree in Healthcare Administration, Business Administration, Compliance, or related field.

Experience

Minimum: At least five years of managed care claims auditing, claims examiner, or claims quality control experience. Two years of experience as a Claims Examiner or Claims Adjuster.

Preferred: Experience in MSO, IPA, or health plan environment. Experience supporting delegated managed care and regulatory audits. Experience auditing professional and institutional claims.

Certification(s)

Preferred: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Professional Compliance Officer (CPCO)

Skills, Knowledge & Abilities

· Strong knowledge of managed care claims processing and audit methodologies.

· Knowledge of CPT, HCPCS, ICD-10, DRG, and reimbursement methodologies.