Claims Auditor, Health Plan

🕒 May 18

🧀 Wisconsin – Remote

🧀 Wisconsin – Remote

💵 $17 - $28 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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Sanford Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1894

⚕️ Healthcare Insurance

Healthcare Insurance

Sanford Health is the largest rural health system in the United States, dedicated to transforming the healthcare experience and providing access to world-class healthcare in America's heartland. Headquartered in Sioux Falls, South Dakota, Sanford Health serves over 1. 4 million patients and nearly 200,000 health plan members across 250,000 square miles. The integrated health system includes 48 medical centers, 211 clinic locations, and more than 160 senior living centers, employing 2,900 physicians and advanced practice providers. Sanford Health is committed to offering compassionate care through its Centers of Excellence, focusing on specialties such as cancer, orthopedics, women’s health, and genetics. Additionally, it provides affordable health insurance, engages in extensive clinical trials, and supports personalized genetic medicine.

📋 Description

• Responsible for performing payment, procedural accuracy, turnaround time, compliance and operational audits on claims as directed by management • Apply effective, appropriate and efficient audit procedures in collecting, analyzing and reporting concise and relevant findings • Develop and maintain a knowledge base of CPT coding guidelines, ICD codes, healthcare common procedure coding system (HCPCS) codes, use of modifiers, documentation guidelines, CMS policy, Medicaid rules, and other reimbursement guidelines to review claims for accuracy, compliance, proper billing and ensure adherence to insurance policies and regulations • Investigate and report claim variances to the appropriate staff for correction • Conduct monthly audits of pre-pay and post-paid claims to verify accuracy of processing, financial, procedural and turnaround time • Review medical records to determine the appropriateness of medical charges on claims that are chosen for complex audit review • Analyze and resolve complex claim processing problems, to ensure timely resolution of questions, audits or system issues • Analyze claim errors and provides reports to management to improve processes, editing or claim workflows

🎯 Requirements

• High school diploma or equivalent required • Successful completion of the following courses per departmental procedures,within one year of hire required: current procedural terminology (CPT), current international classification of diseases (ICD), health care procedure coding system (HCPCS) and medical terminology • Associates degree in business, medical or related field preferred • Three years of experience related to health insurance claim processing required • Three years of experience related to CPT/HCPCS and current ICD coding • Demonstrated proficiency with analytical problem solving, written and oral communications and the Microsoft Office Suite • Working knowledge of anatomy & physiology • One year experience in claims auditing preferred • Certified Professional Coder (CPC) or Certified Professional Coder – Payer (CPC-P) certification awarded by the American Academy of Professional Coders (AAPC) at time of hire preferred

🏖️ Benefits

• Flexible scheduling options • Remote work