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Claims Auditor
American Health Partners. Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials .
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, ensuring compliance with CMS requirements and maintaining quality standards. Proficient in using automated claims processing systems and standard coding materials relevant to the healthcare industry.
Highest-signal resume keywords
Claims Processing For Medicare And MedicaidCMS Requirements KnowledgeAutomated Claims Processing SystemsCPT4, ICD10, And HCPCS CodingManaged Healthcare Environment Experience
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 Payment ProcessingRegulatory ComplianceQuality AssuranceError CorrectionClaims Project ManagementComplex Claims ProcessingStandard Coding KnowledgeHealthcare Delivery System ExperienceCustomer Service
Soft Skills
Attention To DetailProblem SolvingCommunicationCollaborationEscalation Management
Tools & Technologies
Automated Claims Processing Systems
Certifications & Qualifications
Coding Certification Preferred
Industry Keywords
MedicareMedicaidSkilled Nursing FacilitiesHealth Insurance IndustryClaims Processing Standards
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 using claims processing standards
- Work closely with the delegated claim processor to review and correct errors before final payment
- Complete assigned claim projects
- Provide customer service to internal and external customers and achieve quality and productivity goals
- Escalate appropriate claims/audit issues to management
- Follow departmental and organizational policies and procedures
- Maintain production and quality standards established by management
- Participate in and support ad-hoc audits
- 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
- Experience with complex claims processing and/or auditing in the health insurance industry or medical health care delivery system: two (2) years
- Experience in a 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: two (2) years
- Coding certification preferred
- Must be able 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
- Reasonable accommodations for qualified individuals with disabilities