Oct 14, 2021

Audit Lead - Full Time, Days (PMS)

  • OneTrust
  • Orange, CA, United States

✍🏾Job Description

Audit 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 Audit Lead perfroms 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

  • Analyze and prepare Health plan claims selections for all health plan/DMHC/CMS audits.
  • Maintain audit schedule.
  • Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor are present at the time of audit.
  • Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows.
  • Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines.
  • Handle complex and urgent audit projects from external provider and internal departments.
  • 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.
  • Log health plan audit findings to ensure root cause ensuring CAP remediation is complete.
  • 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.
  • 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. Demonstrated leadership skills, ability to coach, mentor and foster a culture of achievement. 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 http://pmh.com/careers/ 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: https://www.eeoc.gov/