Claims Auditor - Full-time

About Us

All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick time, and vacation time as well as a 401k plan. Additional employee paid coverage options available. Job purpose The Claims Auditor is responsible for performing detailed audits of institutional and professional claims to ensure accuracy, compliance, and adherence to regulatory and contractual requirements. This role supports the integrity of the claims process by identifying errors, trends, and opportunities for process improvement. Duties and responsibilities

• Conduct retrospective and concurrent audits of claims to verify accuracy of payment, coding, and rate application.
• Review claims for proper application of Division of Financial Responsibility (DOFR), benefit matrix interpretation, and regulatory compliance.
• Validate application of DRG, APC, ASC, and PPS payment methodologies.
• Identify trends and root causes of claim processing errors and recommend corrective actions.
• Assist with preparation of audit findings and reports for management review.
• Support internal quality control by providing feedback and training recommendations.
• Collaborate with the Claims Audit Director to ensure consistent audit methodology and reporting standards.
• Maintain knowledge of current CMS, DMHC, and DHS regulations as well as company policies related to claims adjudication.
• Participate in special projects, focused audits, or process improvement initiatives as assigned.

Qualifications

• Minimum 5–7 years of experience in HMO or managed care claims processing, including experience with both institutional and professional claims.
• Strong understanding of ICD-10, CPT, and HCPCS coding principles.
• Knowledge of payment methodologies including DRG, APC, ASC, PPS, and other applicable rate structures (Medicare, Medi-Cal, and Commercial).
• Familiarity with regulatory requirements (CMS, DMHC, DHS) and claims settlement practices (AB1324, AB1455).
• Proficient in interpreting benefit matrices and DOFR.
• Strong analytical, problem-solving, and documentation skills.
• Proficiency in Microsoft Excel and Word.
• Excellent written and verbal communication skills.

About Us

All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick time, and vacation time as well as a 401k plan. Additional employee paid coverage options available. Job purpose The Claims Auditor is responsible for performing detailed audits of institutional and professional claims to ensure accuracy, compliance, and adherence to regulatory and contractual requirements. This role supports the integrity of the claims process by identifying errors, trends, and opportunities for process improvement. Duties and responsibilities

• Conduct retrospective and concurrent audits of claims to verify accuracy of payment, coding, and rate application.
• Review claims for proper application of Division of Financial Responsibility (DOFR), benefit matrix interpretation, and regulatory compliance.
• Validate application of DRG, APC, ASC, and PPS payment methodologies.
• Identify trends and root causes of claim processing errors and recommend corrective actions.
• Assist with preparation of audit findings and reports for management review.
• Support internal quality control by providing feedback and training recommendations.
• Collaborate with the Claims Audit Director to ensure consistent audit methodology and reporting standards.
• Maintain knowledge of current CMS, DMHC, and DHS regulations as well as company policies related to claims adjudication.
• Participate in special projects, focused audits, or process improvement initiatives as assigned.

Qualifications

• Minimum 5–7 years of experience in HMO or managed care claims processing, including experience with both institutional and professional claims.
• Strong understanding of ICD-10, CPT, and HCPCS coding principles.
• Knowledge of payment methodologies including DRG, APC, ASC, PPS, and other applicable rate structures (Medicare, Medi-Cal, and Commercial).
• Familiarity with regulatory requirements (CMS, DMHC, DHS) and claims settlement practices (AB1324, AB1455).
• Proficient in interpreting benefit matrices and DOFR.
• Strong analytical, problem-solving, and documentation skills.
• Proficiency in Microsoft Excel and Word.
• Excellent written and verbal communication skills.

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