Claims Audit Representative

Join a diversified health and well-being company dedicated to helping people live healthier lives and making the health system work better for everyone. We are a global leader in clinical expertise, advanced technology, and data-driven insights. Our team operates at the intersection of care and commerce, ensuring that millions of members receive accurate, timely, and high-quality healthcare services. This role sits within our specialized Claims Operations division, where precision and integrity are our highest priorities.Position SummaryWe are seeking a high-performing Claims Audit Representative for a 6-month temporary assignment. This role is designed for a claims professional who thrives in a metric-driven environment and possesses deep expertise in California healthcare markets. You will support the organization by ensuring accuracy, compliance, and quality within the claims lifecycle, directly impacting financial and member outcomes.Location: 100% Remote (Must reside in and work during Pacific Daylight Time)Schedule: Monday – Thursday, 5:45 AM – 4:15 PM PST (4/10 Work Week)Compensation: $21.33 per hourContract Duration: March 30, 2026 – September 30, 2026 (6-Month Assignment)Key ResponsibilitiesPre-Lag Auditing: Audit daily pre-lag reports to ensure accuracy, completeness, and strict compliance with required turnaround times (TAT).Compliance Monitoring: Monitor regional pre-lag reports daily and escalate any potential compliance issues or payment timeliness risks.Error Identification: Review daily/weekly reports and check run reports for assigned IPAs to identify and resolve inconsistencies.Member Support: Review and resolve member Out-of-Pocket (OOP) issues with a focus on benefit interpretation.Expert Analysis: Utilize root cause and trend analysis to identify systemic issues within adjudication logic.Required Skills & QualificationsEducation: High School Diploma or equivalent required.Years of Experience: Minimum of 3+ years of medical claims processing experience is strictly required.Market Expertise: Proven experience handling Medi-Cal and HMO claims and benefits.Technical Savvy: Strong familiarity with EZCap or similar major claims adjudication platforms.Adjudication Logic: Deep understanding of health plan benefits, copay/coinsurance application, authorization requirements, and basic coding (ICD, CPT, HCPCS).Schedule Commitment: Ability to work the early-start 4/10 shift (Monday–Thursday) starting at 5:45 AM PST.Team CultureCollaborative & Supportive: A tight-knit team of 5 working toward collective accuracy goals.Detail-Focused: A culture that rewards precision and a "get it right the first time" mentality.Fast-Paced: Metric-oriented environment with a strong emphasis on continuous improvement.