Special Process Quality Auditor performing audits in special process areas for aerospace. Ensuring compliance with NADCAP and customer requirements at various manufacturing sites.
About the role
- Billing Auditor responsible for auditing claims and verifying payment accuracy at Pacific Health Group. Focused on revenue integrity and process improvements within healthcare billing.
Responsibilities
- Reconcile every submitted claim against EOBs, 835 remittance advices, and payment records to verify we received full and accurate reimbursement.
- Audit PEPM payments against enrollment rosters, service logs, and LOA rate schedules across all MCP contracts.
- Identify underpayments, denials, zero-pays, and systematic payment discrepancies—then drive resolution.
- Prepare and file appeals for denied or underpaid claims with complete supporting documentation.
- Cross-reference clinical documentation, care plans, and EHR records against claims to find unbilled and under-billed services.
- Verify correct coding across HCPCS, CPT, and ICD-10—including CalAIM-specific ECM codes (G9007, G9008, G9012), CS codes and BH/SMHS codes.
- Build and maintain audit dashboards tracking denial rates, days in A/R, collection rates, and payer-level variances.
- Produce monthly revenue reconciliation reports for leadership with actionable findings.
- Recommend and implement process improvements that prevent revenue leakage at the source.
Requirements
- 3+ years in medical billing, claims auditing, or revenue cycle management in healthcare.
- Hands-on experience auditing EOBs, reconciling payments, and managing denials and appeals.
- Working knowledge of HCPCS, CPT, and ICD-10 coding.
- Proficiency with EHR/billing systems and strong Excel or Sheets skills for data analysis.
- Sharp analytical instincts and relentless attention to detail.
- Bachelor’s degree in healthcare administration, HIM, business, accounting, or equivalent experience.
- BONUS POINTS
- Experience with Medi-Cal managed care, CalAIM (ECM/CS), or behavioral health billing.
- Familiarity with PEPM/capitated payment models.
- CPC, CCS, or equivalent coding certification.
- Knowledge of 837/835 electronic transaction standards.
- Background in community health, FQHCs, or integrated care settings.
Benefits
- 401(k) matching
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
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