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Department:  Business Services
Status:  Full Time
Shift:  1st

The Claims Delegation QA Specialist is responsible for coordinating health plan audits, regulatory compliance audits, financial compliance as it pertains to claims processing for the Hoag Clinic MSO.  This role works closely with Hoag Corporate Compliance to align with Hoag’s Compliance Program by creating processes to ensure appropriate claim processing and timely responses to audits.


Essential Functions

  • Coordinate the preparation, scheduling, reporting, and successful completion of claims audits by the health plans, regulatory, and financial agencies.
  • Work with Hoag Data Analytics team to define and provide timely and accurate claims reports (e.g., Monthly Timeliness Reports, Quarterly Reports for Claims/Provider Dispute Resolution, Organization Determination Appeals Grievances reports) as required by the health plans, CMS, and the DMHC.
  • Review audit requirements, prepare documents, and assemble packages for each audit category.
  • Assist with developing an audit control checklist for claims timeliness, payment accuracy, systematic or statistical errors in the claims system and process.
  • Perform pre-audit of claims to be audited including validation of claims adjudication processes (e.g., timeliness, payment accuracy, benefit determination, authorization, eligibility, EOB, provider/member denial letter, etc.).
  • Report pre-audit results to Hoag Corporate Compliance.
  • Communicate results, findings, and issues from the audit results to MSO leadership and Hoag Chief Compliance Officer
  • Work with health plan auditor for audit agenda, department overview, ad-hoc requests for information.
  • Develop a root cause analysis report for common trends to provide feedback to claims leadership and Corporate Compliance.
  • Identify root cause of errors or issues to avoid or minimize re-work and address front-end process and issues.
  • Distribute Corrective Action Plans to the appropriate functional area (claims operations, IT, Managed Care, etc.) as well as Hoag Corporate Compliance.
  • Assist in developing Corrective Action Plans that remediate the issues and findings.
  • Review and monitor Corrective Action Plans for completion. 
  • Ensure SLA between teams are adhered to.
  • Assist with the development of claims process improvements that includes reviewing daily processes and providing suggestions to leadership.
  • Support the claims team in implementing initiatives in improving claims processing efficiency.
  • Specialize in the end-to-end process of claims adjudication to include having strong knowledge of processing all service types, provider types, and lines of business.
  • Assist in completing special projects related to delegation oversight audits.
  • Mentor on the team that leads aspects of training function.
  • Works closely with Hoag Corporate Compliance and provides regular reports on audits, corrective action plans, issues identified and remediation recommendations and efforts.
  • Subject matter expert in a variety of knowledge sets and process improvement activities.
  • Perform other duties as assigned.


Education, Training and Experience

Required: High School Diploma or equivalent, 5 years of experience in a medical claims processing environment, knowledge of HMO/managed care regulatory guidelines

Preferred: Experience with Epic Tapestry system


Skills or Other Qualifications


Strong moral compass and commitment to Hoag’s values

Motivated to learn, continually improve and operate to one’s fullest potential

Positive attitude, passionate, excited, strong desire to simplify processes.

Experience in providing excellent customer service, empathetic ability

Skills to multi-task and manage competing priorities, apply critical thinking to solve problems

Tech savvy and posses a capability to quickly learn new applications

Ability to maintain composure and compassion while addressing a high volume of competing tasks

Comfortable with ambiguity and open to collaborative environments

Microsoft Word, Excel, Typing/Data Entry

Strong working knowledge of regulatory guidelines in managed care (Title 22, AB1455, AB1203, AB1324, AB72, CMS guidelines, COB guidelines, etc.)



License and Certifications



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