Claims Auditor

American Health Partners; Indianapolis (IN); Híbrido; USD 65.000 - 90.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Affordable Medical/Dental/Vision

Generous paid time-off

TeleMedicine 24/7/365

Disability plans

Employee Assistance Plan

401K retirement

Referral Bonus

Descripción de la vacante

American Health Plans is seeking a claims processing auditor to ensure accurate Medicare/Medicaid payments and denials, with strong CMS rule knowledge. The role involves audits, regulatory compliance, and collaboration with a delegated processor, with a hybrid schedule including onsite days in Franklin, TN.

Qualified candidates will have 2+ years in complex claims processing or auditing within the health insurance sector and familiarity with CPT4, ICD10, HCPCS coding.

Formación

• Two (2) years’ experience with complex claims processing and/or auditing in health insurance or healthcare delivery systems.
• Two (2) years’ experience in managed care environment related to claims processing/audit.
• Two (2) years’ experience with standard coding and reference materials used in a claim setting (CPT4, ICD10, HCPCS).
• Two (2) years’ experience with CMS requirements regarding claims processing; especially Skilled Nursing Facility rules.

Responsabilidades

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

Conocimientos

Claims processing

CMS rules

Auditing

Customer service

Regulatory compliance

Communication

Herramientas

Automated claims processing systems

Descripción del empleo

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.