Remote Claims Auditor | Medicare & Medicaid Compliance

SCAN Group; Long Beach (CA); Remote; USD 35,000 - 51,000; Full time

Benefits offered by this job

Remote work

Annual bonus program

Paid time off

Job summary

SCAN Group is seeking a Claims Auditor to perform pre- and post-pay audits of claims payments and denials, ensuring accuracy and regulatory compliance. You will apply strong knowledge of CMS requirements and work with the Claims Department to review processing errors prior to final payment.

The role requires 3+ years in claims processing/auditing within health plans or managed care, familiarity with CMS guidelines, and experience with IKA and QNXT.

Qualifications

• 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.

Responsibilities

• 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 to maintain efficient and compliant operations; communicate suggestions for improvement and efficiencies to management.

Education

Associate's degree preferred or equivalent experience

Tools

IKA

QNXT

Job description

SCAN Group is seeking a Claims Auditor to perform pre- and post-pay audits of claims payments and denials, ensuring accuracy and regulatory compliance. You will apply strong knowledge of CMS requirements and work with the Claims Department to review processing errors prior to final payment.

The role requires 3+ years in claims processing/auditing within health plans or managed care, familiarity with CMS guidelines, and experience with IKA and QNXT.