Claims Auditor in Orange at Prospect Medical Systems

Date Posted: 11/4/2020

Job Snapshot

Job Description

Claims Auditor

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Claims Auditor performs analysis and monitors trends identified through the audit process.  This individual will take the lead to ensure accurate and timely adjudication of claims, as well as identifying potential issues and recommending strategies for resolution.  Apply claim and/or inquiry processing experience to audit and analyze simple to advanced-level claims processing procedures and workflows.

Job Responsibilities/Duties

  • Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows.  Requires the ability to audit claims accurately. Independently run reports on errors identified for potential error trends and report the results to Claims Management and Claims Trainer. Additionally assist in the processing of PDRs , Health Plan Cap Deducts, and claims processing.
  • Handle special projects from external provider and internal departments.  Must have the ability to accurately make the necessary adjustments for underpayments and review overpayment requests for Claims Recovery Specialist.
  • Independently audit and analyze high dollar claims and checks prior to the issuance of funds.  Must possess the ability to analyze Claims EOB and balance check amounts according to Claims processing guidelines.
  • Analyze and prepare Health plan claims selections for Annual health plan audit.  Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor is present at the time of audit.
  • Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests.  Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines.


Minimum Education:  High School Diploma or Equivalent. BS/BA preferred.

Minimum Experience:  Two to three (2-3) years previous experience as medical claims Auditor or 3-5 years previous experience examining medical Claims preferred. Preferably in an IPA, MSO, or Medical Group setting.

Req. Certification/Licensure:   None

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol.  Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm.  For this reason, we require applicants to pass a screening for drug use as a condition of employment.  This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.

How to Apply

To apply for this role, or search our other openings, please visit  and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law:

Keywords: Claims Auditor, Auditor