Senior Health Plan Auditor III

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Salary Range : $88,854 (Min.) - $115,508 (Mid.) - $142,164(Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission : L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Specialty Health Plans Auditor III is responsible for all aspects of planning, execution, reporting, and corrective action plans, monitoring of financial solvency, and claims processing compliance for specialty health plans and vendors. These audits are intended to ensure that L.A. Care delegates comply with regulatory requirements and L.A. Care contractual agreements across all lines of business.

The position is responsible for the Department of Managed Health Care (DMHC) claims data submissions for L.A. Care and its Plan Partners (PPs) and tasks are delegated each quarter and annually. Primarily responsible for the creation, review, and submission of departmental policies and procedures annually.

Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.

Duties

Performs financial audits and / or financial analyses for Specialty Health Plans on a quarterly and annual basis

Performs financial analyses or vendor management for L.A. Care vendors on a quarterly and annual basis.

Performs annual claims audits for Specialty Health Plans and vendors.

Provides timely and accurate deliverables to ensure financial solvency and claims processing compliance with regulatory and contractual requirements for plan partners, participating provider groups, capitated hospitals, specialty health plans, and vendors.

Collaborates in the creation and implementation of standardized Specialty Health Plans and vendors’ workpaper and reporting templates.

Collects and completes quarterly and annual (DMHC) filing submissions.

Is cross trained on financial solvency reviews for Participating Physician Group (PPGs), PPs, and capitated hospitals.

Serves as primary contact and liaison for Centers for Medicare and Medicaid Services (CMS) claim audit section of L.A. Care delegates.

Reviews and updates annually the department’s Policies and Procedures (P&Ps). Ensures that any new or updated Policy and Procedure is reviewed and approved by management prior to submission.

Supports the formalization of key internal processes and monitoring tools.

Accountable for the completion of requests from Legal Department, Delegation Oversight’s monitoring oversight and reporting.

Responsible for the overall communication and collaboration with interdepartmental personnel, leadership, specialty health plans, and vendors.

Collaborates on the design, implementation, and reporting of special projects

Education Required

Bachelor's Degree in Accounting or Related Field

In lieu of degree, equivalent education and / or experience may be considered.

Experience

Education Preferred

Required :

At least 3 years of experience in conducting financial audits.

At least 5 years of related experience in the managed health care industry.

Skills

Minimum of 2 years of accounting experience

Required :

Strong analytical skills and organizational abilities.

Action-oriented, self-starter, and excellent motivator.

Licenses / Certifications Required

Must have one of the certifications below :

CPA, CIA, CMA, or CFE

Additional Information

Salary Range Disclaimer : The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care Offers a Wide Range Of Benefits, Including

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental, and Vision
• Wellness Program

Seniority level

Seniority level

Mid-Senior level

Employment type

Employment type

Full-time

Job function

Job function

Finance and Accounting / Auditing

Industries

Hospitals and Health Care

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Inferred from the description for this job

Medical insurance

Vision insurance

401(k)

Tuition assistance

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