Claims Auditor

Jobtailor

Oklahoma

Hybrid

USD 60,000 - 90,000

Full time

14 days+

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Job summary

Jobtailor is seeking a Health Insurance Claims Auditor to conduct pre- and post-pay audits for Medicare/Medicaid, ensuring CMS compliance and high-quality processing. You will collaborate with delegated processors to correct errors before payments and support ad-hoc audits.

The role requires hands-on experience with Institutional and Professional claims, CPT4/ICD10 coding, and a hybrid work model with possible 2–3 days onsite at the Franklin, TN office.

Qualifications

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.
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.
Coding certification preferred.

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
Perform other duties as assigned

Skills

Claims Processing

Medicare Auditing

CMS Requirements

CPT4 Coding

ICD10 Coding

Education

Coding Certification

Tools

Automated Claims Processing Systems

Job description

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
Perform other duties as assigned

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
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
Coding certification preferred
Hybrid role that may require 2-3 days per week onsite at the Franklin, TN office
Ability to perform essential functions satisfactorily, with or without a reasonable accommodation

Core Competencies

Demonstrates expertise in processing and auditing claims for Medicare and Medicaid, with a strong understanding of CMS requirements and complex claim processing regulations. Proven ability to maintain quality standards and provide exceptional customer service in a managed healthcare environment.

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