Claims Auditor

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Louisiana, Iowa, and Idaho with planned expansion into other states in 2024. For more information, visit AmHealthPlans.com . If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application! Benefits and Perks include: 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 ESSENTIAL JOB DUTIES: To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation. 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 processor to ensure errors are reviewed and corrected prior to final payment Work assigned claim projects to completion Provide a high level of customer service to internal and external customers; achieve 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 Other duties as assigned JOB REQUIREMENTS: 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 Hybrid role that may require 2-3 days per week onsite at the Franklin, TN office. REQUIRED QUALIFICATIONS: Experience: 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 License/Certification(s): Coding certification preferred 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.