Claims Auditor

Ascendo-Resources; Miami (FL); On-site; USD 65,000 - 90,000; Full time

Job summary

Ascendo-Resources is seeking an experienced Claims Auditor to join a healthcare organization in the United States. The role focuses on performing pre- and post-payment audits, ensuring CMS and Medicare compliance, and improving claims processing quality.

The ideal candidate has 5+ years of claims processing experience and at least 1 year of auditing experience, with strong CPT/HCPCS/ICD-10 coding knowledge and analytical skills.

Qualifications

• 5+ years of claims processing experience
• 1+ year of claims auditing or quality audit experience
• Medicare/CMS and managed care experience preferred
• Strong knowledge of CPT, HCPCS, and ICD-10 coding
• Strong analytical, research, and problem-solving skills
• Attention to detail and accuracy
• Ability to work independently and manage multiple priorities

Responsibilities

• Perform pre- and post-payment audits of healthcare claims, including high-dollar and complex claims.
• Review claims processed by claims examiners for accuracy and compliance.
• Validate member eligibility, coding, pricing, reimbursement, authorization requirements, and medical necessity.
• Review CPT, HCPCS, and ICD-10 coding.
• Ensure claims are processed according to CMS Medicare guidelines and internal policies.
• Audit underpayment disputes and identify payment discrepancies or processing errors.
• Document audit findings, financial discrepancies, and decision rationale.
• Track audit trends and identify recurring claims processing issues.
• Recommend corrective actions and process improvements.
• Work with internal departments to research and resolve complex claims issues.
• Provide feedback regarding claims processing errors and quality concerns.
• Identify potential overpayment and recovery opportunities.

Job description

We are seeking an experienced Claims Auditor to join a healthcare organization and support the accuracy and quality of Medicare claims processing. This position will be responsible for performing pre- and post-payment audits, identifying discrepancies, ensuring compliance with CMS guidelines, and helping improve overall claims processing quality.

Responsibilities

• Perform pre- and post-payment audits of healthcare claims, including high-dollar and complex claims.

• Review claims processed by claims examiners for accuracy and compliance.

• Validate member eligibility, coding, pricing, reimbursement, authorization requirements, and medical necessity.

• Review CPT, HCPCS, and ICD-10 coding.

• Ensure claims are processed according to CMS Medicare guidelines, internal policies, and clinical requirements.

• Audit underpayment disputes and identify payment discrepancies or processing errors.

• Document audit findings, financial discrepancies, and decision rationale.

• Track audit trends and identify recurring claims processing issues.

• Recommend corrective actions and process improvements.

• Work with internal departments to research and resolve complex claims issues.

• Provide feedback regarding claims processing errors and quality concerns.

• Identify potential overpayment and recovery opportunities.

Qualifications

• High School Diploma or GED required.

• 5+ years of claims processing experience, preferably within healthcare or insurance.

• 1+ year of claims auditing or quality audit experience required.

• Medicare/CMS and managed care experience strongly preferred.

• Strong understanding of claims adjudication and reimbursement methodologies.

• Knowledge of CPT, HCPCS, and ICD-10 coding.

• Strong knowledge of medical terminology and claims processing systems.

• Experience with underpayment disputes or payment integrity is a plus.

• Strong analytical, research, and problem-solving skills.

• Excellent attention to detail and accuracy.

• Ability to work independently and manage multiple priorities in a production-driven environment.