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Claims Auditor
American Health PartnersClaims Auditor auditing Medicare and Medicaid payments for American Health Plans’ senior-focused I-SNPs. Ensuring accurate claims, regulatory compliance, and correction of processing errors.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in processing and auditing claims for Medicare and Medicaid, with a strong understanding of CMS requirements and complex claim processing regulations. Proven ability to maintain quality standards and provide exceptional customer service in a managed healthcare environment.
Highest-signal resume keywords
Claims ProcessingMedicare AuditingCMS RequirementsCPT4 CodingICD10 Coding
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AuditingClaims ProcessingMedicaid ClaimsInstitutional Claims PaymentsProfessional Claims PaymentsAutomated Claims Processing SystemsStandard CodingHCPCS CodingComplex Claims ProcessingQuality Standards Maintenance
Soft Skills
Customer ServiceProblem SolvingAttention to DetailCommunication
Certifications & Qualifications
Coding Certification
Industry Keywords
Health InsuranceManaged HealthcareSkilled Nursing FacilityRegulatory ComplianceAudit Issues
About the role
Key responsibilities & impact- 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 closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment
- Work assigned claim projects to completion
- Provide a high level of customer service to internal and external customers; achieve quality and productivity goals
- Escalate appropriate claims/audit issues to management as required; follow departmental/organizational policies and procedures
- Maintain production and quality standards as established by management
- Participate in and support ad-hoc audits as needed
- Perform other duties as assigned
Requirements
What you’ll need- Proficient in processing/auditing claims for Medicare and Medicaid plans
- Strong knowledge of CMS requirements regarding claims processing, especially regarding skilled nursing facilities and other complex claim processing rules and regulations
- Current experience with both Institutional and Professional claim payments
- Knowledge of automated claims processing systems
- Two (2) years’ experience with complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system
- Two (2) years’ experience in managed healthcare environment related to claims processing/audit
- Two (2) years’ experience with standard coding and reference materials used in a claim setting, such as CPT4, ICD10 and HCPCS
- Two (2) years’ experience with CMS requirements regarding claims processing; especially Skilled Nursing Facility and other complex claim processing rules and regulations
- Two (2) years’ experience processing/auditing claims for Medicare and Medicaid plans
- Coding certification preferred
- Hybrid role that may require 2-3 days per week onsite at the Franklin, TN office
- Ability to perform essential functions satisfactorily, with or without a reasonable accommodation
Benefits
Comp & perks- Affordable Medical/Dental/Vision insurance options
- Generous paid time-off program and paid holidays for full time staff
- TeleMedicine 24/7/365 access to doctors
- Optional short- and long-term disability plans
- Employee Assistance Plan (EAP)
- 401K retirement accounts
- Employee Referral Bonus Program