Claims Auditor

SCAN

. Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials.

Posted 11/10/2026full-timeRemote • California • United StatesMid-LevelSenior💰 $25 - $37 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in complex claims processing and auditing within healthcare, with a strong focus on regulatory compliance and quality assurance. Proficient in Medicare and Medicaid claims, coding standards, and automated claims processing systems.

Highest-signal resume keywords

Complex Claims ProcessingAuditing ExperienceRegulatory ComplianceMedicare And Medicaid ClaimsAutomated Claims Processing Systems

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AuditingCPT4 CodingICD9 CodingICD10 CodingDRG KnowledgeHCPCS KnowledgeDOFR KnowledgeCOB KnowledgeHealth Insurance TrainingMedical Terminology

Soft Skills

Customer ServiceCollaborationCommunicationProblem SolvingAttention To Detail

Tools & Technologies

IKAQNXTClaims Processing Systems

Industry Keywords

Managed CareHealthcareClaims Processing StandardsFederal And State Regulatory Requirements

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 assigned cases through SCAN’s workflow system and apply correct status attributes to track and trend issues.
Notate cases and audits with required detail regarding status and final resolutions.
Collaborate with Claims Department units to review and correct processing errors before final payment.
Follow policies and procedures; communicate improvement and efficiency suggestions to management.
Identify and report workflow problems through proper departmental procedures.
Participate in departmental staff meetings and training sessions.
Provide high-level customer service to internal customers while meeting quality, productivity, and attendance expectations.
Escalate claims and audit issues to management as required.
Maintain production and quality standards established by management.
Participate in ad-hoc audits as needed.
Support department initiatives, communication, collaboration, knowledge sharing, and issue resolution.
Support SCAN’s members and providers and contribute to team efforts.
Support SCAN’s Vision and Goals.
Perform other duties as assigned.

Requirements

What you’ll need

Associate’s degree preferred or equivalent experience
3+ years complex claims processing and/or auditing experience with a health plan, healthcare, or managed care organization.
Proficient in processing/auditing claims for Medicare and Medicaid plans.
Strong knowledge of CMS requirements regarding claims processing.
Working knowledge of DOFR (Division of Financial Responsibility), COB (Coordination of Benefits).
Current experience in both Institutional and Professional claim payment.
Knowledge of standard coding and reference materials used in a claim setting, such as CPT4, ICD9, ICD10, DRG and HCPCS.
Completion of health insurance training and medical terminology or equivalent knowledge through on-the-job training and experience.
Knowledge of health care benefit structures and insurance procedures, as they exist in a Managed Care environment.
Knowledge of automated claims processing systems, preferably IKA, and QNXT.
Background check required.
Must follow applicable Federal and State regulatory requirements and guidelines.

Benefits

Comp & perks

Annual bonus program
Robust Wellness Program
Generous paid-time-off (PTO)
Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday
Excellent 401(k) Retirement Saving Plan with employer match and contribution
Robust employee recognition program
Tuition reimbursement
An opportunity to become part of a team that makes a difference to our members and our community every day!