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Senior Health Plan Compliance Auditor - Irvine, CA

UnitedHealth Group

Irvine, CA
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Job Details

740323 Senior Health Plan Compliance Auditor Irvine CA

Senior Health Plan Compliance Auditor - Irvine, CA (740323)

Position Description

Responsible for claims data analysis, development of report specs to support audit oversight and preparation for health plan and regulatory audits based on regulatory requirements, internal policies, and industry standards. Requires knowledge of current and emerging regulatory requirements, and use of industry-standardized tools.


Primary Responsibilities:

  • Maintains oversight to health plan and regulatory audit requests by developing and preparing required data reports. Manages reporting changes and performs quality audits for accuracy of reports in alignment with requested report criteria

  • Maintains data library and performs annual review of reports to maintain reporting integrity

  • Prepares Monthly Timeliness and health plan/regulatory audit reports

  • Performs complex pre-audits in preparation for scheduled audits and documents findings on appropriate forms

  • Researches claim processing problems and errors to determine their origin and appropriate resolution.  Prepares reports for management summarizing observations and recommendations

  • Assists management with their evaluation of controls and acts as a consultant to suggest ways to mitigate risk areas

  • Completes audit and internal corrective action plans (CAP) based on audit findings and monitors to ensure future compliance

  • Participates in communication with Business Operations management regarding results of claims audit process in order to improve processes and payment integrity

  • Provides qualified data for incorporation into training programs, policies and procedures, and standard operating procedures

  • Performs special project audits and reviews as requested by other departments/regions

  • Regular and consistent attendance

Required Qualifications:

  • 3+ years of experience with Medical Claims experience

  • Experience working with Medicare / Medicaid / HMO

  • Knowledge of healthcare regulations and guidelines including CMS and MHC as pertains to AB1455

  • Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms, and CPT Coding


Preferred Qualifications:

  • Associate's Degree (AA) or equivalent experience

  • Intermediate skill levels in Microsoft Word, Excel and Outlook

  • Ability to write routine reports and correspondence

  • Ability to speak effectively before groups of customers or employees of the organization

  • Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to concepts of basic algebra

  • Ability to common sense understanding to carry out instructions furnished in written, oral, and diagram form

  • Ability to deal with problems involving several concrete variables in standardized situations

  • Detail oriented


What's the first thing that happens when one of the most successful physician groups in Orange County comes together with a global leader in health care? Opportunity. With Monarch HealthCare joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. With a vibrant network of hospitals and urgent care centers, we're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do your life's best work.(sm)


Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.


Job Keywords: Claims examiner, Medicare, HMO, disputes, resolution, AB1455, provider, appeals, CCI, Health plans, Correct Coding Initiative, HCFA-1500, UB-92, CPT Coding, Irvine, CA, California

Job Details

  • Contest Number740323
  • Job TitleSenior Health Plan Compliance Auditor - Irvine, CA
  • Job FamilyClaims
  • Business SegmentOptumCare

Job Location Information

  • Irvine, CA
    United States
    North America

Additional Job Detail Information

  • Employee StatusRegular
  • ScheduleFull-time
  • Job LevelIndividual Contributor
  • ShiftDay Job
  • TravelNo
  • Telecommuter PositionNo
  • Overtime StatusNon-exempt

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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