Claims Audit Specialist

Job description

At WelbeHealth, we serve our communities’ most vulnerable seniors through shared intention, pioneering spirit, and the courage to love. These core values and our participant-focus lead the way no matter what. The Claims Audit Specialist is accountable for ensuring the timely and accurate payment or denial of claims while meeting federal/state regulations, provider agreement terms, and company policies and procedures. This role requires a strong knowledge of health plan operations, including the proper processing of professional, institutional, and dental claims, coding, CMS/Medi-Cal regulations, and in-depth comprehension of provider contracts and agreements. The Claims Audit Specialist collaborates effectively with Plan Operations leadership to identify trends that require escalation and training needs, and suggest process improvements. This role is different because the Claims Audit Specialist at WelbeHealth: - Ensures accuracy and compliance by auditing complex Medicare and Medi-Cal claims, directly impacting financial integrity, regulatory adherence, and provider trust - Plays a key role in identifying trends, mitigating risk, and driving process improvements across claims oper...