Claims Quality & Audit Examiner

Solis Health Plans; Town of Florida (NY); On-site; USD 26,000 - 32,000; Full time

Job summary

Solis Health Plans in Doral, Florida seeks a seasoned Claims Audit and Quality Supervisor to lead the review and improvement of claims processing. You will oversee the claims quality program, setting best practices and guiding a team to ensure accurate payments and regulatory compliance.

The role focuses on CMS rules, auditing, and performance improvements, with collaboration across networks and internal teams. This is a full-time, on-site position in the Miami area.

Qualifications

• Strong working knowledge of claims processing standards, CMS claims processing requirements and various Medicare fee schedules.
• Knowledge of automated claims processing systems and other complex claim processing rules and regulations.
• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to Health Plan operations.

Responsibilities

• Configure, implement and administer a robust claims quality and auditing program.
• Establish best practice claims payment methodology based on current CMS claims payment regulations.
• Conduct root cause analysis on systemic issues; formulate action plan to avoid incorrect payment through review of contracts, Medicare claims payment rules, internal system and beneficiary impact.
• Coordinate with Network Services and Provider Relations teams to ensure proper reimbursements.
• Work closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment.
• Conduct pre-pay and post-pay audits to verify accurate claim payments and/ or denials.

Skills

CMS claims rules

Regulatory compliance

Claims processing standards

HCPCS CPT ICD knowledge

Job description

Solis Health Plans in Doral, Florida seeks a seasoned Claims Audit and Quality Supervisor to lead the review and improvement of claims processing. You will oversee the claims quality program, setting best practices and guiding a team to ensure accurate payments and regulatory compliance.

The role focuses on CMS rules, auditing, and performance improvements, with collaboration across networks and internal teams. This is a full-time, on-site position in the Miami area.