Financial Compliance Auditor III, Claims

Job DescriptionJob DescriptionFinancial Compliance Auditor III – ClaimsLocation: Los Angeles, CA (Local required)
Work Style: Mostly remote — onsite only for initial training and occasional meetings
Pay: $63–$66/hour (W2)
Type: Contract (13 weeks, potential extension)
SummaryThe Financial Compliance Auditor III (Claims) supports the Financial Compliance Unit with auditing claims processed by medical groups and contracted health plans. This role ensures compliance with timeliness and appropriateness standards across Medi-Cal, Medicare, Covered California, and PASC-SEIU. The Auditor independently performs claim audits, prepares reports, monitors plan partner performance, and serves as a subject matter expert and mentor within the team.Key Responsibilities

• Perform claims audits for medical groups and health plans; prepare audit workpapers and deliver reports within required timelines.
• Evaluate whether claims processing meets contractual and regulatory requirements (timeliness, accuracy, appropriateness).
• Compile and submit the Monthly Timeliness Report (MTR) and provide claims data reporting in the Online Monitor Tool (OMT).
• Support quarterly and annual oversight of plan partners and IPAs.
• Analyze medical group and plan partner performance; communicate findings concisely and accurately.
• Assist with financial statement analysis and plan partner oversight.
• Conduct sub-delegation claims oversight audits of PPGs, capitated hospitals, and plan partners.
• Prepare and maintain complete, timely audit workpapers prior to onsite reviews.
• Serve as a subject matter expert for claims auditing, mentor junior staff, and provide cross-training.
• Perform other duties as assigned.

Required Qualifications

• Education: Bachelor’s Degree (Master’s ); equivalent education/experience considered.
• Experience: Minimum of 5 years in claims auditing or claims processing with Medi-Cal, Medicare, Covered California, or PASC-SEIU.
• Skills:
  • Self-motivated, detail-oriented, able to prioritize and work independently or as part of a team.
  • Excellent verbal/written communication and analytical skills.
  • Professional communication with internal and external stakeholders.
  • Strong knowledge of healthcare legislation, regulatory bodies, and compliance requirements.
  • Familiarity with medical records systems applications.
  • Knowledge of health insurance products, market segments, and industry trends.
  • Flexible mode of transportation for occasional off-site work.

Qualifications

• Healthcare auditing experience in managed care environments.
• Experience with claims processing oversight in large healthcare networks.

Please feel free to reach out to me directly Suzy at Sekstrom@fuzehr.com


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