Audit Specialist

Plan Operation Audit Specialist

WelbeHealth is a value-based healthcare organization that’s transforming the future of senior care by providing an all-inclusive care option to our most vulnerable senior population. We step in as the care provider and care planner that work to keep our participants within their communities, out of institutions, and cared for like family, all while receiving the healthcare and social services needed to thrive.

The Plan Operations Audit Specialist will be accountable for validating various system configurations to ensure accurate processing of claims in accordance with provider agreements, regulatory guidelines, and company policy. The Plan Operations Audit Specialist will assist with the oversight, monitoring, and auditing of other functional areas within Health Plan Services, including Claims, Contracting, Credentialing and Provider Partnership.

Essential Job Duties:

• Monitor and validate participant eligibility updates and provider terminations to ensure timely updates to claims processing system
• Review performance of claims functions pertaining to claims processing and provider disputes in order to complete monthly audits and quarterly reporting
• Participate in annual plan operations audit to eliminate deficiencies and stay compliant from a contract and regulatory perspective
• Perform audits of provider Medicare/Medicaid/Medi-Cal enrollment, credentialing, and network adequacy
• Regularly provide feedback and detailed documentation of audit findings to Plan Operations leadership regarding configuration errors, and identify quality improvement opportunities when applicable
• Assist with the adjustment of audit tools to keep audit processes current

Job Requirements:

• Bachelor’s degree in relevant field; professional experience may be substituted
• Minimum of five (5) years of experience in healthcare claims electronic processing system
• Minimum of two (2) years of experience with compliance and regulatory audits
• Experience working with CMS and Medi-Cal based health plan operations
• Strong comprehension of provider contracts and agreements as it relates to claim reimbursement
• Proficient experience with all Microsoft Suite applications
• Working knowledge of the health plan insurance industry, CPT/HCPCS procedure codes, ICD-10 codes, and relevant federal and state regulations

Benefits of Working at WelbeHealth Apply your expertise in new ways as we rapidly expand. You will have the opportunity to design the way we work in the context of an encouraging and loving environment where every person feels uniquely cared for. 

• BENEFITS: Health Coverage on Day 1, Paid Parental Leave, 401K Match.
• PERKS:  17 days of paid time off in year one, 12 company holidays, and 6 sick days
• GROWTH: Career path advancement and leadership opportunities