Medicare Claims Auditor

Location: Orange, California US


Job Number: 3674

Position Title: Claims Auditor

External Description:

Position Summary:

The Claims Auditor is responsible for reviewing claims processed by examiners based on provider and health plan contractual agreements and claims processing guidelines.  Follows all internal processes and procedures to ensure claims audit activities are handled in accordance with departmental and company policies and procedures. Excellent knowledge of claims processing rules and Medicare regulatory requirements.  Maintains production standards as established by departmental management to meet quality requirements, ensure payment integrity, identify root cause and training opportunities.


General Duties/Responsibilities:

(May include but are not limited to)


  • Reviews claims for statistical and payment accuracy. Ensure appropriate payments or denials, and use of adjustment or reason codes are correct
  • Identifies root cause of errors and work with internal departments for resolution
  • Review claims for fraud, waste or abuse and notifies management of such findings.
  • Updates systems, tracking tools or other documentation methods as needed.
  • Identifies data trends and reports findings to department management with suggestion for resolution and opportunities for process improvement.
  • Prepares and issue audit reports which include audit findings, scores and corrective actions
  • Monitors completion of corrections
  • Assists with training of claims examiners based on identified errors
  • Submit monthly audit reports to Management.
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.
  • Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.).
  • Actively participates in ongoing training to support company and department initiatives.
  • Supports department initiatives in improving processes and workflow efficiencies
  • Adheres to all regulatory and company standards, as described in the Employee Handbook and departmental Policies and Procedures.
  • Complies with company’s time and attendance policy.
  • Promotes teamwork and cooperation with other staff members and management
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.
  • Performs additional related duties as assigned by Management


Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


  1. Minimum Experience:
    1. 3+ years medical claims auditing experience in HMO or IPA/Medical Group setting required, preferably Medicare claims
    2. 5+ years’ experience in examining all types of medical claims, preferably Medicare claims
  2. Education/Licensure:
    1. Bachelor’s degree in healthcare management or related field, a plus
  3. Other:
    1. Experience working with Provider Dispute and Appeals
    2. Proficiency in Microsoft Office programs (Excel, Access, Word), intermediate level
    3. Experience using claims processing systems (EZCAP preferred).
    4. Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.
    5. Working knowledge of different claims payment methodologies and claim editing guidelines
    6. Familiarity with CMS regulations related to Part C claims
    7. Understanding of Division of Financial Responsibility on how they apply to claims processing
    8. Knowledge of claims processing requirements which include but not limited to eligibility, HMO benefit structures and coordination of benefits
    9. Proven problem-solving skills and ability to translate knowledge to the department.
    10. Ability to multitask.
    11. Strong Organizational Skills.
    12. Attention to Detail.
    13. Ability to use 10 key.
  4. Work Environment
    1. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is 

  1. is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
  2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Medicare Claims Auditor

Company Profile:

Alignment Health was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time.

By becoming a part of the Alignment Health team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment community.

EEO Employer Verbiage:

Alignment requires all new hires to follow local and/or state requirements regarding the COVID-19 vaccine and booster.  If applicable, proof of vaccination and booster will be required as a condition of employment subject to legal exemptions.  This policy, which Alignment reserves the right to modify, is part of Alignment’s ongoing efforts to ensure the safety and well-being of its staff and community and to support public health efforts.

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.

If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact [email protected].

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].