Prospect Medical Systems - CA Job - 41056147 | CareerArc
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Company: Prospect Medical Systems - CA
Location: Los Angeles, CA
Career Level: Associate
Industries: Hospitals, Health Care


Current Employees Click HERE

Current employees can apply directly through the Internal Careers Center online for Prospect Medical job openings in California. For a streamlined application process, all you need is your four-digit employee ID number and a digital copy of your résumé handy before you apply.

Note: Internal applicants not eligible for any Sign On Bonus.


Internal Claims Auditor Lead - Full Time, Days (PMS)

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Internal Claims Auditor Lead performs advanced health plan/DMHC/CMS audits, monitor trends, and perform special analyses.  This individual will take the lead to ensure health plan documents are submitted timely, as well as identifying potential issues, and recommending strategies for resolution.  Individual is responsible for monitoring audit due dates and analyzing complex project and reports results directly to management.  Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer.

Job Responsibilities/Duties
  • Ensures adherence to the daily and scheduled focused audit plan.
  • Actively engages in Root Cause analysis of deficiencies, and lead efforts in development and implementation of effective remediation and process improvement solutions.
  • Proactively identifies focus areas for audits based on trends/data and inputs from external audits and makes required adjustments
  • Works in close partnership and collaboration with the Claims Operations and PDR teams, Configuration team, Contracting Team, and IT team to identify areas of opportunities and/or issues and risks based on internal audit findings. 
  • Adjusts and aligns audit tactics to quickly respond to changing priorities and business needs; ensures flexibility of the department through effective communication of business rationale.
  • Develops and maintains an environment that encourages teamwork and communication and supports quality and process improvement suggestions and solutions
  • Accurately document the underpayments and overpayments into the audit database. 
  • Assist management with analyzing Claim error trends.
  • Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer.
  • Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/ Finance, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution.
  • Collaborates with internal staff to develop and implement processes, policies and procedures and other activities to ensure State and Federal standards and requirements are followed.
  • Works with the Claim Operations team and Configuration team to develop and implement audit processes to comply with Medicaid (including Medi-Cal) and Medicare processing guidelines.
  • Identify training needs/ gaps for the team and ensure timely and effective training is imparted to all team members.

Minimum Education: A High School Diploma or Equivalent required.  BS/BA preferred.

Minimum Experience: Previous two (2) years' experience as Medical Claims Auditor or 7 years previous experience examining Claims required. Strong independent decision-making, influencing and analytical skills. Extensive knowledge of claims processing guidelines including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines.

Req. Certification/Licensure: None. 

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol.  Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm.  For this reason, we require applicants to pass a screening for drug use as a condition of employment.  This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.

How to Apply

To apply for this role, or search our other openings, please visit and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law:

Position Summary

Employment Status: Regular Full-time

Shift: Days

Work Schedule: Monday - Friday

Address: Orange - 600 City Parkway West, Suite 800



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