Claims Auditor

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

Benefits offered by this job

Remote work

Annual bonus program

Wellness program

PTO

Eleven paid holidays

401(k) match

Tuition reimbursement

Job summary

SCAN Health Plan seeks a detail‑oriented Claims Auditor to conduct pre‑ and post‑pay audits, ensuring accurate payments and CMS compliance. The role requires experience with Medicare/Medicaid claims, and knowledge of CMS requirements, DOFR/COB, and automated processing systems.

Ideal candidates will have an Associate's degree (or equivalent) and 3+ years in complex claims processing, with proficiency in IKA and QNXT. Remote work is offered with a strong wellness and bonus program.

Qualifications

• Associate's degree or equivalent experience preferred.
• 3+ years in complex claims processing and/or auditing in health plan or managed care.
• Proficient in Medicare/Medicaid claims processing.

Responsibilities

• Perform pre-pay and post-pay audits to ensure accurate payments.
• Ensure regulatory compliance and quality using CMS standards.
• Work with other units to correct processing errors before final payment.
• Follow policies; communicate improvement recommendations to management.

Skills

Claims auditing

Medicare/Medicaid

CMS regulations

DOFR/ COB

Coding systems CPT4 ICD9 ICD10 DRG HC…

IKA / QNXT

Health insurance training

Institutional & Professional claims

Education

Associate's degree or equivalent

Tools

IKA

QNXT

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-not dilute-not 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 Claims Auditor

• 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 apply 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.

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