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.
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.
Knowledge of health plan contracts, fee schedules, and DOFR agreements.
Knowledge of DMHC, CMS, DHCS, and regulatory requirements.
Strong analytical and problem-solving skills.
Ability to interpret and apply complex regulatory and contractual requirements.
Strong attention to detail and audit documentation skills.
Excellent written and verbal communication skills.
Proficiency with claims systems such as EZ Cap and Microsoft Office applications.
Ability to work independently and meet audit deadlines.
Ability to maintain confidentiality and data integrity.
Physical, Mental & Environmental Requirements
The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in an office or hybrid office environment and involves prolonged periods of sitting, computer use, and document review. The role requires sustained concentration, analytical thinking, and attention to detail to ensure claims accuracy and regulatory compliance. Light physical effort may be required, including lifting up to approximately 10 pounds and occasional bending, reaching, or filing. This role requires the ability to maintain confidentiality and professionalism when handling sensitive claims and compliance information.
Pay Range
$28.85 - $33.65 / hourly
Quality Control Auditor • San Bernardino, CA, United States
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