Claims Auditor

SHPCA SCAN Health Plan; United States; Remote; USD 35,000 - 51,000; Full time

Benefits offered by this job

Remote work

Annual bonus

PTO

Holidays

401(k) match

Tuition reimbursement

Wellness program

Job summary

SCAN Health Plan seeks a Claims Auditor to perform pre-pay and post-pay audits, ensuring accurate claims payments and denials. You will work in a remote environment, applying CMS rules and COB/DOFR knowledge to improve processes and compliance.

You will collaborate with the Claims Department, aiming for quality, productivity, and timely resolutions while supporting ad-hoc audits and continuous improvement initiatives across the team.

Qualifications

• Associate’s degree preferred or equivalent experience.
• 3+ years complex claims processing and/or auditing experience with a health plan, healthcare, or managed care organization.
• Proficient in processing/auditing claims for Medicare and Medicaid plans.
• Strong knowledge of CMS requirements regarding claims processing.
• Working knowledge of DOFR, COB.
• Experience in Institutional and Professional claim payments.
• Knowledge of CPT4, ICD9, ICD10, DRG, HCPCS.
• Health insurance training and medical terminology experience.
• Knowledge of healthcare benefit structures in managed care.
• Experience with automated claims processing systems, preferably IKA and QNXT.

Responsibilities

• Audit pre-pay and post-pay claims to ensure accuracy.
• Collaborate with the Claims Department to correct processing errors.
• Follow federal and state regulations and company policies.
• Provide high level internal customer service and escalate issues as needed.
• Participate in ad-hoc audits and department initiatives.

Skills

Claims auditing

CMS requirements

COB knowledge

IKA/QNXT

Medicare/Medicaid

Healthcare terminology

Health-plan experience

Education

Associate degree

Tools

CPT4/ ICD9/ ICD10

DOFR knowledge

Job description

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the 12 Angry Seniors. Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity. At SCAN, we believe scale should strengthen-our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve.

The Job

The Claims Auditor will perform various audits of claims payments and denials to ensure accuracy. You Will 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 assigned cases through SCAN's workflow system, and applies correct status attributes to track and trend issues. Notate cases/audits with required detail to ensure that others understand status of case/audit and final resolutions. Work closely with other units within the Claims Department to ensure processing errors are reviewed and corrected prior to final payment. Follow policies and procedures in order to maintain efficient and compliant operations; communicate suggestions for improvement and efficiencies to management; identify and report problems with workflows following proper departmental procedures; actively participate in departmental staff meetings and training sessions. Follow all appropriate Federal and State regulatory requirements and guidelines applicable to SCAN Health Plan operations or as documented in company policies and procedures.

Provide a high level of customer service to internal customers by consistently meeting and/or exceeding team expectations including but not limited to quality, productivity and attendance. Escalate appropriate claims/audit issues to management as required and follow departmental/organizational policies and procedures. Maintain required levels of production and quality standards as established by management. Participate in and supports ad-hoc audits as needed. Contribute to overall department success by participating in department initiatives, effective communication and collaboration with all members of the SCAN team through knowledge and idea sharing, take ownership to identify and report issues to appropriate management staff for resolution and work actively with the SCAN team to improve the support to our Members and Providers. Contribute to team effort by accomplishing related results as needed. We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. Actively support the achievement of SCAN's Vision and Goals. Other duties as assigned.

Your Qualifications

• Associate’s degree preferred or equivalent experience
• 3+ years complex claims processing and/or auditing experience with a health plan, healthcare, or managed care organization.
• Proficient in processing/auditing claims for Medicare and Medicaid plans.
• Strong knowledge of CMS requirements regarding claims processing.
• Working knowledge of DOFR (Division of Financial Responsibility), COB (Coordination of Benefits).
• Current experience in both Institutional and Professional claim payment.
• Knowledge of standard coding and reference materials used in a claim setting, such as CPT4, ICD9, ICD10, DRG and HCPCS.
• Completion of health insurance training and medical terminology or equivalent knowledge through on-the-job training and experience.
• Knowledge of health care benefit structures and insurance procedures, as they exist in a Managed Care environment.
• Knowledge of automated claims processing systems, preferably IKA, and QNXT.

What’s in it for you?

• Base wage range: $25.38 to $36.76 per hour
• Work Mode: Remote
• Annual bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday
• Excellent 401(k) Retirement Saving Plan with employer match and contribution
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more. SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law.

A background check is required.

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)

Become part of a mission-driven team that makes a difference in the lives of seniors every day. SCAN has a long history of finding and investing in ways to meet seniors' needs. This focus is what attracts employees to SCAN. For each and every one of us, the SCAN mission is personal. Keeping Seniors Healthy and Independent is both our mission and our passion. That same commitment carries over to our employees. We provide the training, tools and support necessary to do your work. We reward effort and celebrate success. SCAN both develops and attracts people who are leading experts in their respective fields. If the SCAN mission is one you believe in too, we invite you to explore the career opportunities at SCAN.

Why consider a career at SCAN?

• A competitive compensation and benefits program
• An annual employee bonus program
• Generous paid-time-off (PTO)
• Eleven paid holidays per year
• Excellent Retirement Savings program
• A work-life balance
• An opportunity to become part of a team that makes a difference to our members and our community every day!

#LI-MS1 #LI-Remote