Claims Auditor

Role Overview

• Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials
• Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of claims processing standards
• Work closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment
• Work assigned claim projects to completion
• Provide a high level of customer service to internal and external customers; achieve quality and productivity goals
• Escalate appropriate claims/audit issues to management as required; follow departmental/organizational policies and procedures
• Maintain production and quality standards as established by management
• Participate in and support ad-hoc audits as needed
• Other duties as assigned

Requirements

• Two (2) years’ experience with complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system
• Two (2) years’ experience in managed healthcare environment related to claims processing/audit
• Two (2) years’ experience with standard coding and reference materials used in a claim setting, such as CPT4, ICD10 and HCPCS
• Two (2) years’ experience with CMS requirements regarding claims processing; especially Skilled Nursing Facility and other complex claim processing rules and regulations
• Two (2) years’ experience processing/auditing claims for Medicare and Medicaid plans
• Coding certification preferred

Benefits

• Affordable Medical/Dental/Vision insurance options
• Generous paid time-off program and paid holidays for full time staff
• TeleMedicine 24/7/365 access to doctors
• Optional short
• and long-term disability plans
• Employee Assistance Plan (EAP)
• 401K retirement accounts
• Employee Referral Bonus Program