Remote Claims Auditor — Medicare/Medicaid (SNF)

American Health Plans; Franklin (TN); Hybrid; USD 60.000 - 85.000; Vollzeit

Benefits dieser Stelle

Health insurance

Paid time off

TeleMedicine 24/7/365 access

Disability plans

EAP

401K

Referral bonus

Zusammenfassung

American Health Plans in Franklin, TN is seeking a claims audit specialist to ensure accurate Medicare/Medicaid payments and regulatory compliance. The role focuses on pre/post-pay audits, collaboration with claim processors, and adherence to CMS rules to reduce denials and improve payment accuracy.

The position offers a hybrid work arrangement (2–3 days onsite weekly) at our Franklin office, with opportunities to contribute to quality improvements and support internal and external customers

Qualifikationen

• Two (2) years’ experience with complex claims processing and/or auditing in health insurance or healthcare delivery.
• Two (2) years’ experience in a managed healthcare environment related to claims processing/audit.
• Two (2) years’ experience with CPT4, ICD10 and HCPCS references in a claim setting.
• Two (2) years’ experience with CMS requirements for claims processing, especially SNF and complex rules.
• Two (2) years’ experience processing/auditing claims for Medicare and Medicaid plans.
• Coding certification preferred.

Aufgaben

• Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials.
• Ensure regulatory compliance and quality/efficiency using claims processing standards.
• Work with delegated claim processor to review and correct errors before final payment.
• Work assigned claim projects to completion.
• Provide high level customer service to internal and external customers; meet quality/productivity goals.
• Escalate issues to management; follow department policies and procedures.
• Maintain production and quality standards as set by management.
• Participate in and support ad-hoc audits as needed.
• Other duties as assigned.

Kenntnisse

Claims processing

Auditing

CMS regulations

Medicare/Medicaid

Regulatory compliance

Jobbeschreibung

American Health Plans in Franklin, TN is seeking a claims audit specialist to ensure accurate Medicare/Medicaid payments and regulatory compliance. The role focuses on pre/post-pay audits, collaboration with claim processors, and adherence to CMS rules to reduce denials and improve payment accuracy.

The position offers a hybrid work arrangement (2–3 days onsite weekly) at our Franklin office, with opportunities to contribute to quality improvements and support internal and external customers