Claims Auditor

American Health Plans; Franklin (TN); Hybrid; USD 55,000 - 70,000; Full time

Benefits offered by this job

Affordable Medical/Dental/Vision

Paid time off & holidays

TeleMedicine 24/7/365

Short- & long-term disability plans

Employee Assistance Plan (EAP)

401K retirement accounts

Employee Referral Bonus Program

Job summary

American Health Plans in Franklin, TN is seeking a claims auditor/processor to ensure accurate Medicare and Medicaid payments, audit pre- and post-pay submissions, and support regulatory compliance.

The role requires knowledge of CMS processing rules, experience with skilled nursing facility claims, and collaboration with delegated processors. Hybrid onsite 2–3 days per week at the Franklin office. This position offers healthcare benefits and a 401(k) plan.

Qualifications

• Two (2) years’ experience with complex claims processing and/or auditing 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

Responsibilities

• 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

Skills

Claims processing

Auditing

CMS guidelines

Customer service

Education

Coding certification preferred

Tools

Automated claims processing systems

Job description

American Health Plans
Franklin, TN 37067, USA

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.