Job Description
The 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.
Qualifications
Education:
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.
Our compensation philosophy
We offer competitive total compensation that includes pay, benefits, and other recognition programs for our employees. The base pay range shown above takes into account the wide range of factors that are considered in making compensation decisions including knowledge/skills; relevant experience and training; education/certifications/licensure; and other business and organizational factors. This base pay range does not include our comprehensive benefits package and any incentive payments that may be applicable to this role. Pay Transparency Non Discrimination Provision (PDF) (opens in new window)
Diversity and Inclusion at Cedars-Sinai
We are caretakers and innovators committed to the pursuit of equitable healthcare. But health equity is not possible without representation. Our commitment to diversity goes beyond demographics or checking boxes. Our people must reflect the diverse identities, experiences and geographies of the communities and patients we serve – because that’s what our patients, colleagues and communities deserve. Quality Care and Research—For All, By All (opens in new window).
Cedars-Sinai is an Equal Employment Opportunity employer.
Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law. If you need a reasonable accommodation for any part of the employment process, please contact us by email at Applicant_Accommodation@cshs.org and let us know the nature of your request and your contact information. Requests for accommodation will be considered on a case-by-case basis. Please note that only inquiries concerning a request for reasonable accommodation will be responded to from this email address.
Cedars-Sinai will consider for employment qualified applicants with criminal histories, in accordance with the Los Angeles Fair Chance Initiative for Hiring.
At Cedars-Sinai, we are dedicated to the safety, health and wellbeing of our patients and employees. This includes protecting our patients from communicable diseases, such as influenza (flu) and COVID-19. For this reason, we require that all new employees receive a flu vaccine based on the seasonal availability of flu vaccine (typically during September through April each year) as a condition of employment, and annually thereafter as a condition of continued employment, subject to medical exemption or religious accommodation. For the same reason, you may also be required to receive other vaccines such as COVID-19 as a condition of employment. Cedars-Sinai reserves the right to make modifications to its required list of vaccines as required by law and/or policy. Cedars-Sinai’s AA Policy Statement (PDF) (opens in new window)