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 Requirements 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 Core Competencies 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 Processing Medicare Auditing CMS Requirements CPT4 Coding ICD10 Coding ATS Optimization Keywords Hard Skills Claims Auditing Claims Processing Medicaid Claims Institutional Claims Payments Professional Claims Payments Automated Claims Processing SystemsStandard Coding HCPCS Coding Complex Claims Processing Quality Standards Maintenance Soft Skills Customer Service Problem Solving Attention to Detail Communication Certifications & Qualifications Coding Certification Industry Keywords Health Insurance Managed Healthcare Skilled Nursing Facility Regulatory Compliance Audit Issues #J-18808-Ljbffr Jobtailor