Claims Auditor- Remote

About the role

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc., owns and operates Institutional Special Needs Plans (I-SNPs) for seniors residing in long-term care facilities. These plans work in partnership with nursing home operators to manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. Currently operating in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Louisiana, Iowa, and Idaho, with planned expansion into additional states in 2024.

Responsibilities

• 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 processors to review and correct errors before final payment
• Provide high-level customer service to internal and external customers; meet 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

Requirements

• Proficient in processing/auditing claims for Medicare and Medicaid plans
• Strong knowledge of CMS requirements regarding claims processing, especially for 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
• Hybrid role requiring 2-3 days per week onsite at the Franklin, TN office

Qualifications

• 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

Skills

Coding certification preferred

Benefits and 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

Pay

Negotiable

Schedule

Hybrid role requiring 2-3 days per week onsite at the Franklin, TN office

Equal Opportunity Employer

Our 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.