Claims Auditor- Bakersfield 1.1

Description

Employment Details:

Location: Bakersfield, CA. 93309 (Onsite)

Classification: Full-Time

This position is non-exempt and will be paid on an hourly basis.

Schedule: Monday-Friday 8am-5pm

Benefits:

· Medical 

· Dental 

· Vision

· Simple IRA Plan

· Employer Paid Life Insurance

· Employee Assistance Program

Compensation: The initial pay range for this position upon commencement of employment is projected to fall between $28.75 and $35.93. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

Position Summary:

The Claims Auditor is responsible for performing detailed reviews of processed medical claims to ensure accuracy, compliance, and adherence to contractual, regulatory, and organizational guidelines. This position plays a critical role in supporting quality assurance initiatives and identifying trends or systemic issues within claims processing. The Claims Auditor will collaborate closely with the Claims team, Compliance, and other departments to support continuous improvement efforts and maintain integrity in claims adjudication processes.

Requirements

Responsibilities:

• Conduct post-payment and pre-payment audits of processed medical claims to ensure compliance with organizational policies, CMS guidelines, and payer-specific requirements.

• Review documentation, coding, eligibility, authorization, and payment accuracy for claims across multiple lines of business.

• Identify and document errors, trends, and opportunities for process improvements.

• Develop clear, concise audit reports and communicate findings to Claims leadership and relevant stakeholders.

• Participate in root cause analysis discussions and help develop action plans for error correction and training.

• Monitor rework efforts to confirm audit corrections are implemented appropriately.

• Collaborate with the Compliance department for regulatory audits and support any required data validation.

• Assist in the development and delivery of training materials based on audit findings.

• Support system testing and implementation of claim system updates or enhancements, as needed.

• Maintain current knowledge of CMS guidelines, ICD/CPT/HCPCS coding changes, and payer policies and reimbursement methodologies including but not limited to Medicare, Medi-Cal, Capitation, Per Diem.

• Other duties as assigned.

Qualifications:

• High School Diploma or GED required, associate or bachelor’s degree in healthcare administration, Business, or related field preferred.

• Minimum of 3 years of experience in medical claims processing, auditing, or quality assurance in a healthcare or MSO environment.

• Experience with Medicare, Medicaid, and commercial claims strongly preferred.

• Strong understanding of medical billing, coding (ICD-10, CPT, HCPCS), and payer rules and guidelines.

• Excellent attention to detail and analytical skills.

• Ability to interpret medical documentation and determine claim appropriateness.

• Proficiency in claims processing software and Microsoft Office Suite, particularly Excel.

• Strong communication skills, both written and verbal.

• Ability to handle sensitive and confidential information with discretion.

• Organized, self-motivated, and able to manage multiple priorities in a fast-paced environment.