Senior Claims Auditor - Managed Care

Senior Claims AuditorThe Senior Claims Auditor serves as the technical lead for complex claims auditing activities. This role is responsible for developing and maintaining audit methodologies, overseeing the accuracy and compliance of claims processing with department policies, CMS, DMHC, and other regulatory standards, and providing advanced analytical support to management. The incumbent leads cross departmental audit initiatives, performs specialized system testing, and supports internal and external regulatory audits.Duties and Responsibilities:Designs, updates, and implements audit methodologies and selection criteria based on prior audit results, regulatory changes, system improvements, and operational trends.Conducts advanced audits on adjudicated claims, including high risk and complex cases, ensuring compliance with policies, payment methodologies, and regulatory requirements.Performs EPIC/Tapestry system testing and validation to ensure claim processing systems and EIS updates function as intended.Serves as primary resource for internal audits, providing detailed validation and documentation.Develops, maintains, and updates departmental SOPs for claims auditing. Mentors and provides technical guidance to junior Claims Auditors.Analyzes audit results to identify trends, root causes, and systemic issues. Delivers actionable recommendations to management for process and operational improvements.Leads cross functional projects involving claims operations, IT, compliance, and other departments to resolve complex audit findings.Produces written and verbal reports summarizing audit findings for leadership, highlighting compliance risks and recommending mitigation strategies.Monitors appeals and disputes involving providers, members, and health plans, ensuring timely and accurate resolution of complex cases.Coordinates and manages multiple audit projects, ensuring deadlines and quality standards are met.Serves as a mentor and technical lead for Claims Auditors, providing guidance and training without direct supervisory authority.Coordinates team participation in special audits, ensuring consistency in methodology and reporting.QualificationsEducation:High school diploma/GED required. Bachelor's degree in healthcare or related field highly preferred.Experience:Five (5) years of professional and facility claims processing for Medicare and Commercial products, including high risk audits and provider dispute resolution required. Experience developing audit methodologies and SOPs required.Two (2) years of Senior/Lead claims auditing experience in a medical claim's environment with demonstrated expertise in regulatory compliance and system testing required.About UsCedars-Sinai is a leader in providing high-quality healthcare encompassing primary care, specialized medicine and research. Since 1902, Cedars-Sinai has evolved to meet the needs of one of the most diverse regions in the nation, setting standards in quality and innovative patient care, research, teaching and community service. Today, Cedars-Sinai is known for its national leadership in transforming healthcare for the benefit of patients. Cedars-Sinai impacts the future of healthcare by developing new approaches to treatment and educating tomorrow's health professionals. Additionally, Cedars-Sinai demonstrates a commitment to the community through programs that improve the health of its most vulnerable residents.About the TeamWith a growing number of primary urgent and specialty care locations across Southern California, Cedars-Sinai's medical network serves people near where they live. Delivering coordinated, compassionate healthcare you can join our network of clinicians and physicians to improve the healthcare people throughout Los Angeles and beyond. Cedars-Sinai