Claims Auditor

SCAN Health Insurance • Long Beach, CA

1d • $25 - $37 • Remote

About The Position

The Claims Auditor performs audits of claims payments and denials to ensure accuracy. The role conducts pre-pay and post-pay audits, applies claims processing standards to support regulatory compliance and quality, and uses SCAN’s workflow system to track cases and issues. The auditor documents cases and audit resolutions, works with other Claims Department units to review and correct processing errors before final payment, and escalates issues when needed.

The position follows applicable policies, procedures, and Federal and State regulatory requirements; maintains established production and quality standards; and provides consistent service to internal customers. The auditor also participates in ad-hoc audits, staff meetings, training, and department initiatives, and collaborates with SCAN colleagues to identify issues and improve support for members and providers. Other duties may be assigned.

Requirements

• At least 3 years of complex claims processing and/or auditing experience with a health plan, healthcare, or managed care organization.
• Proficiency processing and auditing claims for Medicare and Medicaid plans.
• Strong knowledge of CMS requirements regarding claims processing.
• Working knowledge of DOFR (Division of Financial Responsibility) and COB (Coordination of Benefits).
• Current experience with 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 gained through on-the-job training and experience.
• Knowledge of healthcare benefit structures and insurance procedures in a managed care environment.
• Knowledge of automated claims processing systems.

Nice To Haves

• Associate’s degree preferred or equivalent experience.
• Experience with IKA and QNXT claims processing systems is preferred.

Responsibilities

• Conduct pre-pay and post-pay audits of claims payments and denials for accuracy.
• Apply claims processing standards to support regulatory compliance, quality, and efficiency.
• Work assigned cases through SCAN’s workflow system and apply status attributes to track and trend issues.
• Document cases and audits with details on status and final resolutions.
• Work with other Claims Department units to review and correct processing errors before final payment.
• Follow policies, procedures, and applicable Federal and State regulatory requirements.
• Communicate suggestions for process improvements and efficiencies, and report workflow problems according to departmental procedures.
• Participate in departmental staff meetings and training sessions.
• Provide internal customer service while meeting or exceeding expectations for quality, productivity, and attendance.
• Escalate claims and audit issues to management as appropriate.
• Maintain production and quality standards established by management.
• Participate in ad-hoc audits and department initiatives, communicate and collaborate with SCAN team members, share knowledge and ideas, and report issues to appropriate management staff.
• Contribute to team efforts and support the achievement of SCAN’s vision and goals.
• Perform other duties as assigned.

Benefits

• Annual bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Eleven paid holidays per year, plus one floating holiday and one birthday holiday
• 401(k) retirement savings plan with employer match and contribution
• Employee recognition program
• Tuition reimbursement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree