Claims Auditor

Job OpportunityAmerican Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Louisiana, Iowa, and Idaho with planned expansion into other states in 2024.If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application!Benefits and Perks include:Affordable Medical/Dental/Vision insurance optionsGenerous paid time-off program and paid holidays for full time staffTeleMedicine 24/7/365 access to doctorsOptional short- and long-term disability plansEmployee Assistance Plan (EAP)401K retirement accountsEmployee Referral Bonus ProgramEssential Job Duties:To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation.Conduct pre-pay and post-pay audits to ensure accurate claims payments and denialsEnsure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of claims processing standardsWork closely with delegated claim processor to ensure errors are reviewed and corrected prior to final paymentWork assigned claim projects to completionProvide a high level of customer service to internal and external customers; achieve quality and productivity goalsEscalate appropriate claims/audit issues to management as required; follow departmental/organizational policies and proceduresMaintain production and quality standards as established by managementParticipate in and support ad-hoc audits as neededOther duties as assignedJob Requirements:Proficient in processing/auditing claims for Medicare and Medicaid plansStrong knowledge of CMS requirements regarding claims processing, especially regarding skilled nursing facilities and other complex claim processing rules and regulationsCurrent experience with both Institutional and Professional claim paymentsKnowledge of automated claims processing systemsHybrid role that may require 2-3 days per week onsite at the Franklin, TN office.Required Qualifications:Experience: Two (2) years' experience with complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery systemTwo (2) years' experience in managed healthcare environment related to claims processing/auditTwo (2) years' experience with standard coding and reference materials used in a claim setting, such as CPT4, ICD10 and HCPCSTwo (2) years' experience with CMS requirements regarding claims processing; especially Skilled Nursing Facility and other complex claim processing rules and regulationsTwo (2) years' experience processing/auditing claims for Medicare and Medicaid plansLicense/Certification(s): Coding certification preferredEqual Opportunity EmployerOur Organization does not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. The Organization will also make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made.This employer participates in E-Verify.Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.