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Job Details

Claims Hospital Audit Manager - Healthcare

Northridge, CA

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As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

We currently have an opening for a Claims Analyst.

The Claims Analyst is responsible to analyze data to identify any potential issues and work under the supervision of the Sr. Director of Claims for quality improvement and payment accuracy.


1. Assisting Sr. Claims Director for any projects internally & externally including any issues and working with Sr. Director to resolve issues timely.

2. Analyze claims based on the contracts, Fee schedule in EZ-Cap system to identify any potential issues and improve the payment accuracy and overall quality.

3. Handle all projects timely and accurately based on health plan, CMS, DMHC, requirements.

4. Analyze the data and run ad-hoc reports for quality improvement.

5. Prepares documentation for Sr. Claims Director as needed.

6. Utilizes standardized processes, tools, methodologies and presentation templates, including: project timetables, progress/milestone reports, financial reports, resource, and issues tracking.

7. Communicates effectively with Sr. Claims Director and all claims production staff, as well as with external vendors, consultants and other organizations.

8. Interacts with Claims Management team and provides feedback to Sr. Director of Claims for improvement.

9. Identifies potential project risks and implements appropriate courses of action to address project slippage and develop strategies to mitigate future risk. Escalates critical issues for appropriate/timely resolution as needed.

10. Monitors time commitments and resources for project teams. Deploys project resources.

11. Works closely with Sr. Claims Director to plan, facilitate, and/or lead team meetings.

12. Supports vendor-related activities such as tracking contract stipulations, invoices, and processing data requests.

13. Provides technical support, training assistance, and expertise to other project managers and staff through all phases of the project (e.g., Initiation, Analysis, Design, Implementation, and Evaluation).

14. Performs other duties as assigned. Qualifications:1. Strong ability to collaborate with management and other project managers to define business process issues, analyze operational efficiencies, implement creative solutions, and measure delivery results

2. Should exhibit a disciplined, process and data-driven approach and methodology

3. Knowledge of claims payment policies preferred

4. Requires strong organizational, communication and written skills

5. Must be able to function with minimal supervision and be able to prioritize all work tasks

6. Demonstrated ability to conduct and interpret qualitative and quantitative analysis and problem-solving skills

7. Ability to work well with individuals in all levels of the organization; Must be an effective team player

8. Demonstrated ability to exercise initiative, independent judgment and be a self-starter

9. Strong PC-based business software skills including MS Office suite (Access, Excel, PowerPoint, Word)

10. Excellent verbal and written presentation and communication skills

We offer a full benefits package which includes employer paid medical, pharmacy and dental benefits. We offer a generous PTO package, 401k Retirement Savings, Life Insurance, Flexible Spending Account (FSA), Tuition Reimbursement & Licensed Renewal Fees for our clinical staff.

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

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