Claims Auditor & Process Improvement Specialist

South Florida Community Care Network Llc; Town of Florida (NY); Hybrid; USD 28,000 - 34,000; Full time

Benefits offered by this job

Hybrid work schedule

Job summary

South Florida Community Care Network LLC in Sunrise, FL is seeking a full-time Claims Analyst to support accurate and timely claims payment through pre-payment audits, analysis, and payment integrity activities. You will review professional and facility claims, identify discrepancies, and work with internal teams to resolve issues and improve processing.

The role requires 5–7 years of claims experience (Associates preferred) and knowledge of ICD-10-CM, CPT, DRG coding, and fee schedules.

Qualifications

• High school diploma or GED required; five to seven years of related claims experience and/or training required.
• Associate degree preferred.
• Medical coding certification such as CPC or equivalent preferred.
• Familiarity with ICD-10-CM, HCPCS Level II and III, CPT, revenue codes, and DRG coding on UB-04 and CMS-1500 claim types.
• Strong knowledge of medical claims processing/adjudication, fee schedules, provider contracts, coverage, reimbursement policies, and claims processing standards.

Responsibilities

• Perform daily claims audits and review professional and facility claims to identify payment errors, discrepancies, and potential high-risk claims before payment.
• Validate claims against member benefits, provider contracts, fee schedules, reimbursement methodologies, and applicable policies and regulations.
• Analyze overpayments, underpayments, duplicate payments, coding issues, and other discrepancies to identify root causes and recommend corrective action.
• Process claims adjustments, reprocessing, corrections, COB updates, refunds, and overpayment recovery activities as needed.
• Support first-level appeals and resolve complex claims-related questions from internal departments.
• Test and validate claims system, benefit configuration, and system enhancements to support accurate claim adjudication.
• Identify opportunities to improve payment accuracy, increase auto-adjudication, reduce manual processing, and strengthen operational efficiency.
• Provide guidance and training to Claims Examiners and contribute to claims procedures, SOPs, and reference materials.
• Communicate audit findings, recurring issues, and recommendations to Claims Leadership and collaborate with internal teams on resolution.
• Assist with audits, implementations, special projects, and other claims-related initiatives.

Skills

Analytical skills

Claims experience

Communication skills

Education

High school diploma or GED

Associate degree preferred

CPC (Certified Professional Coder) or equivalent

Job description

South Florida Community Care Network LLC in Sunrise, FL is seeking a full-time Claims Analyst to support accurate and timely claims payment through pre-payment audits, analysis, and payment integrity activities. You will review professional and facility claims, identify discrepancies, and work with internal teams to resolve issues and improve processing.

The role requires 5–7 years of claims experience (Associates preferred) and knowledge of ICD-10-CM, CPT, DRG coding, and fee schedules.