Auditor, Provider Data

Auditor, Provider Data

Join us in this amazing opportunity. We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

We are hoping you will join us as an Auditor, Provider Data and help shape the future of healthcare where you'll be an integral part of our Provider Data Operations team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework.

If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

You will be responsible for conducting ongoing data quality auditing of CalOptima Health's provider network data, which includes working with internal departments and health networks to remediate data errors. You will perform within the Provider Data Operations department to ensure that regulatory and internal guidelines are being followed in conjunction with CalOptima Health's policies and procedures. You will provide analytical and administrative support specific to the Provider Data Operations department. You will be responsible for auditing CalOptima Health's provider data, which involves specialized background or knowledge regarding contract setup, provider data requirements, directories requirements and claims processing. You will often work independently and duties include research, analysis, documentation and reporting responsibilities. Together, we are building a stronger, more equitable health system.

Your contributions to the team :

95% - Auditing functions

Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.

Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals / priorities for the department.

Assists with audits of the department's data entry activities into CalOptima Health's provider data management systems.

Compiles and summarizes data reports and writes audit results to internal committees and meetings with recommendations for improvement.

Works with health networks, providers and internal departments to obtain audit information and presents findings and recommendations as appropriate.

Audits processes and activities to ensure accuracy and compliance for programs, including the provider directories, onboarding and term processes, health network data for network certification and adequacy and the 274 file.

Works with vendors and leverages internal and external tools to audit and improve provider data accuracy and integrity.

Reviews and break downs regulatory requirements to identify data impact for audit process updates and implementation.

Assists with implementing and monitoring Corrective Action Plans for regulatory compliance and / or operational compliance.

Maintains a well-documented audit trail.

Maintains ongoing reporting formats for use in data auditing and conducts independent analysis of audit results.

Maintains ongoing knowledge of provider data requirements and set up within the organization's provider management systems.

Analyzes regulatory audit requirements, develops workplans and processes.

Conducts data integrity activities to support CalOptima Health's goal of maintaining a high rate of accuracy.

5% - Completes other projects and duties as assigned.

Do you have what the role requires?

Bachelor's degree in healthcare administration or related field PLUS 2 years of experience working with provider data in a health care or managed care environment required, preferably in a related area of responsibility, such as utilization management, quality management or provider data management; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

Have access to means of transportation for work away from the primary office approximately 15% of the time required.

You'll stand out more if you possess the following :

Experience with regulatory compliance and provider data management.

What the regulatory agencies need you to possess?

N / A

Your knowledge & abilities to bring to this role :

Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.

Work independently and exercise sound judgment.

Communicate clearly and concisely, both orally and in writing.

Work a flexible schedule; available to participate in evening and weekend events.

Organize, be analytical, problem-solve and possess project management skills.

Work in a fast-paced environment and in an efficient manner.

Manage multiple projects and identify opportunities for internal and external collaboration.

Motivate and lead multi-program teams and external committees / coalitions.

Utilize computer and appropriate software (e.g., Microsoft Office : Word, Outlook, Excel, PowerPoint) and job specific applications / systems to produce correspondence, charts, spreadsheets, and / or other information applicable to the position assignment.

Your physical requirements (with or without accommodations) :

Ability to visually read information from computer screens, forms and other printed materials and information.

Ability to speak (enunciate) clearly in conversation and general communication.

Hearing ability for verbal communication / conversation / responses via telephone, telephone systems, and face-to-face interactions.

Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.

Lifting and moving objects, patients and / or equipment 10 to 25 pounds

Ways we are here for you :

You'll enjoy competitive compensation for this role.

Our current hiring range is : Pay Grade : 309 - $68,015 - $108,824 ($32.70 - $52.3192). The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.

This position is approved for Full Telework (If the position is Telework, it is eligible in California only).

CalPERS pension program and additional retirement packages.

Additional benefits and perks including :

A generous PTO program

A quality work life balance

Various wellness programs

Tuition Reimbursement

Professional development opportunities

Career development opportunities

Flexible scheduling

And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.

Our work environment :

If located at the 500, 505 Building or a remote work location :

Work is typically indoors and sedentary and is subject to schedule changes and / or variable work hours, with travel as needed.

There are no harmful environmental conditions present for this job.

The noise level in this work environment is usually moderate.

If located at PACE :

Work is typically indoors in a clinical setting serving the frail and elderly.

There may be harmful or hazardous environmental conditions present for this job.

The noise level in this work environment is usually moderate to loud.

If located in the Community :

Work is typically indoors and sedentary and is subject to schedule changes and / or variable work hours, with travel as needed.

Employee will occasionally work outdoors in varied temperatures.

There may be harmful or hazardous environmental conditions present for this job.

The noise level in this work environment is usually moderate to loud.

Why join us?

We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impact on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.

What's your next step?

All applications will be accepted on