Remote Claims Auditor – Health Plan Compliance & QA

SHPCA SCAN Health Plan; United States; Remote; USD 35.000 - 51.000; Vollzeit

Benefits dieser Stelle

Remote work

Annual bonus

PTO

Holidays

401(k) match

Tuition reimbursement

Wellness program

Zusammenfassung

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.

Qualifikationen

• 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.

Aufgaben

• 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.

Kenntnisse

Claims auditing

CMS requirements

COB knowledge

IKA/QNXT

Medicare/Medicaid

Healthcare terminology

Health-plan experience

Ausbildung

Associate degree

Tools

CPT4/ ICD9/ ICD10

DOFR knowledge

Jobbeschreibung

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.