Claims Auditor

Leon Medical Centers•Doral, FL

About The Position

The Claims Auditor ensures accurate and timely claims processing by conducting pre-payment and post-payment validations, supporting operational reporting and testing, and managing data submissions. The role ensures claims comply with established policies, guidelines, contractual agreements, provider rates, and Medicare payment requirements. The Claims Auditor also supports payment-related coordination, provider education and outreach, dispute and reimbursement processing, and reporting.

Requirements

High school diploma or GED equivalent.
At least five years of experience in healthcare claims processing, or an equivalent combination of education, training, and experience.
Fluent in English and Spanish.

Nice To Haves

Medicaid and Medicare claim processing experience preferred.

Responsibilities

Apply Medicare claim payment rules and requirements, including National Coverage Decisions, Local Coverage Decisions, and National Correct Coding requirements.
Enter claim data accurately and promptly in accordance with departmental production and quality goals.
Ensure claim payments are made within contractual time frames and maintain at least 98% accuracy.
Conduct pre-payment and post-payment audits to validate coding and documentation, including CPT, HCPCS, and ICD-10, and confirm appropriate adjudication rules and fee schedules were applied.
Conduct pre-payment audits of high-dollar claims.
Apply policies and procedures to confirm claims meet payment criteria and comply with Leon Health contractual guidelines.
Research and manage difficult, non-routine, or escalated claims using knowledge of Medicare payment rules.
Identify and manage third-party liability (TPL) or coordination of benefits (COB) cases reported by CMS, providers, or members.
Conduct outreach and recovery efforts with Third Party Administrators.
Coordinate with the Finance department regarding claim payments, voids, and refunds.
Apply adjustments to the claim payment system as necessary.
Refer claims for medical management review when applicable.
Contact providers to request additional information, including medical records, to validate Medicare criteria before approving payment.
Educate providers on billing and prior authorization requirements to help reduce claim rejections and denials.
Review and process provider payment disputes according to Leon Health policies and contractual requirements.
Review and process member requests for claim reimbursement.
Create and distribute claim inventory and aging reports as needed.
Create ad hoc claim data extracts as needed.
Create and validate claim reports (Organizational Determinations) before submission to CMS to ensure data files are accurate and complete.
Assist with effectuating appeals overturned by Leon Health or a federal contractor or entity.