Quality Control Auditor

JOB SUMMARY

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.