Claims Auditor

Job not on LinkedIn

🔥 0 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $25 - $36 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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SCAN

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1977

🏥 Healthcare

⚕️ Healthcare Insurance

👥 B2C

Healthcare • Healthcare Insurance • B2C

SCAN is a mission-driven healthcare organization focused on reinventing aging by delivering evidence-based, patient-centered care and coverage for older adults. It operates an integrated portfolio including health insurance plans with innovative benefits, in-home and virtual primary care, support programs for caregivers and homebound older adults, and specialized services for vulnerable populations. SCAN also invests in and partners with companies that advance care models and resources to help older adults remain healthy and independent at home.

📋 Description

• 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

• 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

• 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!

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