CSC A&G Auditing Specialist
CSC A&G Auditing Specialist
Administrative, HR, Business Professionals
CSC Appeals & Grievance (348)
Los Angeles HQ, California, US
Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
The CSC A&G Quality Assurance Auditing Specialist is responsible for assisting the A&G Compliance, Training and QA Manager to develop a successful and cohesive unit with a high level of productivity and focus on implementing, executing, tracking, and assessing targeted and random audits for non-clinical grievance and appeal case documentation. Ensure G&A Non-Clinical staff is following all Regulatory guidelines, internal P&Ps, Desktop Procedures, in a consistent and accurate manner. This position will focus on quality review of non-clinical grievance and appeals cases for all LOB to identify areas of improvement to assist the department in increasing positive audit outcomes and improved Customer Service to L.A. Care’s membership. QA Reviewer is responsible for monitoring A&G Specialists, Lead Intake, and Senior A&G Specialists, performance against key performance indicators and recognizes trends that require individual or group retraining. The position conducts/reviews audits and analyzes the data and documentation and provides their input to management for review. In addition, is responsible for review and approval of all member letters prior to issuance. This position facilitates recommendations for the development, review, and revision, as appropriate, of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational and departmental guidelines. Generates results of findings, enhances and analyzes various standard reports related to, but not limited to: quality and accuracy of case documentation. This position will work with department Supervisors, Managers and Director for all problems related to quality improvements as needed to increase staff knowledge of L.A. Care, regulations, and departmental requirements. Compiles and presents quality report cards to measure quality enhancements and disseminates to appropriate parties as needed.This position will keep the QA Manager aware of trends, deficiencies and any potential issues that arise for review and evaluation by the Management Team.
QUALIFICATIONS AND REQUIREMENTS
High School Diploma
Associate's or Bachelor's Degree
Bilingual in one of LA Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.
With High School Diploma: 5 years experience in auditing Appeals & Grievances in a healthcare environment required.
Previous experience with Medi-Cal and Medicare in a managed care environment.
With Associate's Degree: 2-4 years experience in auditing Appeals & Grievances in a healthcare environment required.
With Bachelor's Degree: 1-3 years experience in auditing Appeals & Grievances in a healthcare environment required.
Supervisory experience in the healthcare arena.
L.A. Care offers a wide range of benefits including
Paid Time Off (PTO)
Medical, Dental and Vision
Volunteer Time Off (VTO)