Claims Auditor

This is a fully remote position, open to applicants in California.

📋 Description

• Perform audits both before and after payment to ensure claims are paid accurately or denied appropriately.

• Ensure compliance with regulations while maintaining overall quality and efficiency in line with claims processing standards.

• Manage assigned cases through SCAN’s workflow system, applying the correct status attributes to monitor and analyze issues.

• Document cases and audits with the necessary details concerning status and final resolutions.

• Collaborate with various units within the Claims Department to review and amend processing errors prior to final payment.

• Adhere to established policies and procedures; share suggestions for improvements and efficiencies with management.

• Identify and report workflow challenges following appropriate departmental protocols.

• Engage in departmental staff meetings and training sessions.

• Deliver high-quality customer service to internal stakeholders while achieving quality, productivity, and attendance goals.

• Escalate claims and audit-related issues to management as necessary.

• Uphold production and quality standards set by management.

• Participate in ad-hoc audits as needed.

• Contribute to department initiatives, communication, collaboration, knowledge sharing, and problem resolution.

• Assist SCAN’s members and providers, contributing to team efforts.

• Align with SCAN’s Vision and Goals.

• Carry out other assigned duties.

⛳️ Requirements

• Associate’s degree preferred or equivalent experience.

• Over 3 years of experience in complex claims processing and/or auditing within a health plan, healthcare, or managed care organization.

• Proficient in auditing and processing claims for Medicare and Medicaid plans.

• Strong understanding of CMS requirements related to claims processing.

• Familiarity with DOFR (Division of Financial Responsibility) and COB (Coordination of Benefits).

• Current experience with both Institutional and Professional claim payments.

• Knowledge of standard coding and reference materials utilized in a claims setting, including CPT4, ICD9, ICD10, DRG, and HCPCS.

• Completion of health insurance training and medical terminology or equivalent knowledge acquired through on-the-job training and experience.

• Understanding of healthcare benefit structures and insurance procedures as they pertain to a Managed Care environment.

• Familiarity with automated claims processing systems, preferably IKA and QNXT.

• Background check required.

• Must comply with relevant Federal and State regulatory requirements and guidelines.

🏝️ Benefits

• Annual bonus program.

• Comprehensive Wellness Program.

• Generous paid-time-off (PTO).

• Eleven paid holidays each year, in addition to one floating holiday and one birthday holiday.

• Excellent 401(k) Retirement Savings Plan with employer matching and contributions.

• Comprehensive employee recognition program.

• Tuition reimbursement.

• An opportunity to join a team that makes a meaningful impact on our members and the community every day!