Medicare Claims Auditor

Solis Health Plans, Inc.; Miami (FL); On-site; USD 70,000 - 95,000; Full time

Job summary

Solis Health Plans, Inc. is seeking a claims processing supervisor to lead quality audits and ensure compliant payments for Medicare and health plans.

The role requires configuring, implementing and administering robust processes, root-cause analysis, and collaboration with network services and delegated processors. The ideal candidate will have strong CMS rules knowledge, experience with HCPCS, CPT and ICD coding, and 2+ years in complex claims processing or auditing within managed care.

Qualifications

• Bachelor’s degree preferred.
• 2 years’ experience with complex claims processing and/or auditing within the health insurance industry or medical healthcare delivery system.
• 2 years’ experience in a managed healthcare environment related to claims processing/auditing, including CMS requirements.
• 2 years’ experience with CMS requirements, and other complex claim processing rules and regulations.
• 2 years’ experience using HCPCS, CPT, ICD, Medicare codes.
• Recent Institutional and Professional claim payment experience.

Responsibilities

• Configure, implement and administer a robust claims quality and auditing program.
• Establish best practice claims payment methodology based on 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.
• Provide exceptional service to providers, internal and external customers in accordance with Company values.
• Forecast all staffing requirements; schedule workforce accordingly.
• Complete regular review of internal reporting (e.g., high dollar claims).
• Ensure regulatory compliance, quality and efficiency.
• Participate and support ad-hoc audits as required.
• Collaborate with Utilization Management Team as necessary.
• Complete all assigned claim projects.

Skills

CMS rules

Claims auditing

Regulatory compliance

Healthcare claims

HCPCS CPT coding

Data analysis

Education

Bachelor’s degree

Tools

Health care IT systems

Job description

Solis Health Plans, Inc. is seeking a claims processing supervisor to lead quality audits and ensure compliant payments for Medicare and health plans.

The role requires configuring, implementing and administering robust processes, root-cause analysis, and collaboration with network services and delegated processors. The ideal candidate will have strong CMS rules knowledge, experience with HCPCS, CPT and ICD coding, and 2+ years in complex claims processing or auditing within managed care.