Claims Auditor

American Health Plans; Franklin (TN); Híbrido; USD 60.000 - 85.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

Paid time off

TeleMedicine 24/7/365 access

Disability plans

EAP

401K

Referral bonus

Descripción de la vacante

American Health Plans in Franklin, TN is seeking a claims audit specialist to ensure accurate Medicare/Medicaid payments and regulatory compliance. The role focuses on pre/post-pay audits, collaboration with claim processors, and adherence to CMS rules to reduce denials and improve payment accuracy.

The position offers a hybrid work arrangement (2–3 days onsite weekly) at our Franklin office, with opportunities to contribute to quality improvements and support internal and external customers

Formación

• Two (2) years’ experience with complex claims processing and/or auditing in health insurance or healthcare delivery.
• Two (2) years’ experience in a managed healthcare environment related to claims processing/audit.
• Two (2) years’ experience with CPT4, ICD10 and HCPCS references in a claim setting.
• Two (2) years’ experience with CMS requirements for claims processing, especially SNF and complex rules.
• Two (2) years’ experience processing/auditing claims for Medicare and Medicaid plans.
• Coding certification preferred.

Responsabilidades

• Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials.
• Ensure regulatory compliance and quality/efficiency using claims processing standards.
• Work with delegated claim processor to review and correct errors before final payment.
• Work assigned claim projects to completion.
• Provide high level customer service to internal and external customers; meet quality/productivity goals.
• Escalate issues to management; follow department policies and procedures.
• Maintain production and quality standards as set by management.
• Participate in and support ad-hoc audits as needed.
• Other duties as assigned.

Conocimientos

Claims processing

Auditing

CMS regulations

Medicare/Medicaid

Regulatory compliance

Descripción del empleo

American Health Plans
Franklin, TN 37067, USA

Locations

Showing 1 location American Health Plans
Franklin, TN 37067, USA
+2 more locations

• Remote
• Managed Care - ISNP
• Full-Time
• Requisition #: CLAIM027176

Description

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Louisiana, Iowa, and Idaho with planned expansion into other states in 2024. For more information, visit AmHealthPlans.com .

Benefits and Perks include:

• 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

ESSENTIAL JOB DUTIES:

To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.

• 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

JOB REQUIREMENTS:

• Proficient in processing/auditing claims for Medicare and Medicaid plans
• Strong knowledge of CMS requirements regarding claims processing, especially regarding skilled nursing facilities and other complex claim processing rules and regulations
• Current experience with both Institutional and Professional claim payments
• Knowledge of automated claims processing systems
• Hybrid role that may require 2-3 days per week onsite at the Franklin, TN office.

REQUIRED QUALIFICATIONS:

• Experience:
  • 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
• License/Certification(s):
  • Coding certification preferred

EQUAL OPPORTUNITY EMPLOYER

Our Organization does not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. The Organization will also make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made.

This employer participates in E-Verify.

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.