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Claims Quality / Audit Rep - Irvine, CA or Long Beach, CA

UnitedHealth Group

Irvine, CA
Job Code:
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Job Details

Claims Quality / Audit Rep - Irvine, CA or Long Beach, CA(Job Number:705988)

This position is responsible for reviewing, investigating and completing the resolution of Provider Disputes in writing as set forth in laws pertaining to AB1455 for Commercial Health Maintenance Organization (HMO) Enrollees of Provider Disputes and Adjustments for Medicare and HMO Enrollees.


Primary Responsibilities:

  • Reviews written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers. Regarding either Professional or Institutional Claims

  • Provide expertise claims support by reviewing, researching, investigating, auditing claims

  • Analyze and identify trends and provides feedback and reports to reduce errors and improve claims processes and performance

  • Responsible for all aspects of quality assurance

  • Performs complex and extensive research, analysis and logical conclusions of paper and electronic claims to resolve disputes by providers, members and health plans

  • Conducts necessary follow-up with internal departments within set timeframes to validate payment integrity related to regulatory agencies, contracts, policy, coding, and system configuration

  • Acts as a department resource and gives support to Customer Service and researches Practice Connect issues for resolution. Responds to provider calls related to provider disputes and appeals for incoming provider/member disputes

  • Identify, trend, and report the Provider Dispute and Adjustment process for Monarch Healthcare management and prepare reports for management summarizing observations and recommendations for quality improvement

  • Provides qualified data to the Business Operations Compliance & Regulatory Manager for incorporation into training programs and policies and procedures. Confers with management to assess training needs in response to identified trends

  • Collaborates with other departments and management to implement and reinforce policy quality standards


**Please note:  This position would be in-office in either our Irvine or Long Beach, CA office locations.  If a candidate is selected for Long Beach, they would need to train in our Irvine office first.

Job Claim Quality
Primary Location US-CA-Irvine
Other Location US-CA-Long Beach
Organization Monarch
Schedule Full-time
Number of Openings 1
Apply on the Company Site

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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