Claims Auditor

Career Center•Franklin, TN

4d•Hybrid

About The Position

American Health Plans, a division of American Health Partners Inc., owns and operates Institutional Special Needs Plans (I-SNPs) for seniors residing 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. The Claims Auditor conducts pre-pay and post-pay audits, ensures accurate claims decisions and regulatory compliance, coordinates with a delegated claims processor, and supports quality and productivity goals. The role is hybrid and may require 2–3 days per week onsite at the Franklin, Tennessee office.

Requirements

Two years of experience with complex claims processing and/or auditing in the health insurance industry or medical health care delivery system.
Two years of experience in a managed healthcare environment related to claims processing or audit.
Two years of experience with standard coding and reference materials used in a claims setting, such as CPT4, ICD10, and HCPCS.
Two years of experience with CMS requirements for claims processing, especially Skilled Nursing Facility and other complex claim processing rules and regulations.
Two years of experience processing or auditing claims for Medicare and Medicaid plans.
Proficiency in processing and auditing claims for Medicare and Medicaid plans.
Strong knowledge of CMS claims processing requirements, particularly for skilled nursing facilities and other complex claims.
Current experience with both Institutional and Professional claim payments.
Knowledge of automated claims processing systems.

Nice To Haves

Coding certification preferred.

Responsibilities

Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials.
Use knowledge of claims processing standards to ensure regulatory compliance and overall quality and efficiency.
Work closely with the delegated claim processor to ensure errors are reviewed and corrected before final payment.
Complete assigned claim projects.
Provide a high level of customer service to internal and external customers and achieve quality and productivity goals.
Escalate appropriate claims and audit issues to management as required, and follow departmental and organizational policies and procedures.
Maintain production and quality standards established by management.
Participate in and support ad-hoc audits as needed.
Perform other duties as assigned.