Claims Auditor

• 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

• 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, ICD
  10 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

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.

• Claims Processing
• Medicare Auditing
• CMS Requirements
• CPT4 Coding
• ICD
  10 Coding

• Claims Auditing
• Claims Processing
• Medicaid Claims
• Institutional Claims Payments
• Professional Claims Payments
• Automated Claims Processing Systems Standard Coding
• HCPCS Coding
• Complex Claims Processing
• Quality Standards Maintenance

• Customer Service
• Problem Solving
• Attention to Detail
• Communication

• Coding Certification

• Health Insurance
• Managed Healthcare
• Skilled Nursing Facility
• Regulatory Compliance
• Audit Issues