Claims Auditor

Leon Medical Centers; Miami (FL); On-site; USD 60,000 - 90,000; Full time

Job summary

LEON Health, Inc. in Miami seeks a detail-oriented Claims Auditor to ensure accurate and timely processing of healthcare claims.

You will perform pre-payment and post-payment validations, support reporting and testing, and manage data submissions while ensuring adherence to policies, guidelines, and provider rates. Minimum five years' claims processing experience; Medicaid/Medicare experience preferred; fluent in English and Spanish.

Qualifications

• Minimum of five years’ experience in healthcare claims processing.
• Medicaid and Medicare claim processing experience preferred.
• Bilingual English/Spanish language skills are a plus.

Responsibilities

• Apply Medicare Claim Payment rules and requirements to claims for payment.
• Enter claim data accurately and timely in line with production goals.
• Ensure claims payments are made within contractual time frames.
• Maintain a minimum 98% accuracy rate.
• Perform pre-payment and post-payment audits for proper coding and adjudication.
• Coordinate with Finance for payments, voids, and refunds; manage adjustments.

Skills

Medicare rules

LCDs & NCDs

CPT/HCPCS/ICD-10 coding

Pre/post-payment audits

Provider outreach

Billing requirements

Prior authorization

Education

High School diploma or GED

Tools

Medicare rules tooling

Job description

We're looking for a detail-oriented Claims Auditor to help ensure accurate and timely claims processing. You’ll perform pre-payment and post-payment validations, support operational reporting and testing, and manage data submissions while ensuring claims align with established policies, guidelines, contractual agreements, and provider rates.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Apply Medicare Claim Payment rules and requirements, including the application of National Coverage Decisions, Local Coverage Decisions, and National Correct Coding requirements to claims received for payment.
• Enter claim data accurately and timely, in alignment with departmental production and quality goals.
• Ensure claims payments are made within time frames as reflected in contractual agreements.
• Maintain a minimum of 98% accuracy at all times.
• Perform pre-payment audits and post payment audits to validate claims for appropriate coding and documentation (including but not limited to CPT, HCPCS, ICD-10 coding) and validate accurate claim adjudication rules and fee schedules were applied.
• Perform pre-payment high dollar claim audits.
• Apply policies and procedures to confirm that claims meet criteria for payment and are in compliance with Leon Health contractual guidelines.
• Manage difficult, non-routine or escalated claims by using comprehensive research and thorough knowledge of Medicare payment rules.
• Identify and manage third party liability (TPL) or coordination of benefits (COB) cases reported by CMS, providers or members. Perform outreach and recovery efforts to Third Party Administrators.
• Coordinate with Finance department for claim payments, voids and refunds. Apply adjustments to the claim payment system as necessary.
• Refer claims for medical management claim review as necessary/applicable.
• Outreach to providers for additional information, including medical records to validate Medicare criteria is met prior to approving a claim for payment.
• Educate providers on billing requirements to reduce claim submission rejections and denials. Educate providers on prior authorization requirements.
• Review and process provider payment disputes according to Leon Health policies and contractual requirements.
• Review and process member requests for reimbursement of claims.
• Create and distribute claim inventory and aging reports as needed. Create ad hoc claim data extracts as needed.
• Create and validate claim reports (Organizational Determinations) prior to submission to CMS to ensure accuracy and completeness of data files.
• Assist in the effectuation of overturned appeals made by Leon Health or federal contractor/entity.

EDUCATION

High School diploma or GED equivalent.

WORK EXPERIENCE

Minimum of five years’ experience in healthcare claims processing, or an equivalent combination of education, training and experience.

Medicaid and Medicare claim processing experience preferred.

LANGUAGE SKILLS

Fluent in English and Spanish.