Claims Auditor

Volunteers of America National Services (VOANS)•Eden Prairie, MN

6d•$56,000 - $65,000•Remote

About The Position

This is more than a job! It’s an opportunity to lead claims processes within a mission-driven healthcare organization. In this role, you will maintain integrity and accuracy of the claims processing system across all PACE programs through claims audits and implementation of corrective actions.

Requirements

High School Diploma required
3+ years of experience with medical billing and coding/claims processing or auditing.
Strong communication and organizational skills
Ability to analyze, problem-solve, and collaborate effectively

Nice To Haves

Associate’s degree or higher preferred.

Responsibilities

Conduct reviews of claims processes against policy provisions and governing regulations to ensure compliance.
Conduct claims audits including standard audits and focused audits, to ensure accuracy and integrity of the claims processing system, working with PACE System Administrator on necessary system updates.
Ensure that claims are processed in compliance with agency and department policies and procedures, contractual agreements, and governing federal and state regulations.
Respond accurately, timely and professionally to all external and internal communications regarding claims audits, ensuring clarity and accuracy in all interactions.
Review and work weekly/monthly claims data reports from the claims processing system and maintain productivity goals set forth.
Review and approve weekly Precheck Registers for all PACE Organizations.
Ensure all claims appeals are worked timely across all PACE Organizations relevant to governing regulations and contract obligations.
Assist claims staff and PACE Organization staff in reviewing situations that may warrant focused claims audits.
Reviews claims for proper billing and processing, including timely submission, compliant coding, required authorizations, and accurate pricing and payment.
Assist staff on questions and issues related to pricing of claims.
Maintain accurate and detailed records of all claims audits, including documentation of actions taken, communications with internal staff, and corrective actions implemented.
Prepare and submit regular reports on claims processing accuracy and trends to the Claims Manager, Director of Health Plan Operations, VP PACE Business Operations, and other relevant stakeholders.
Maintain knowledge of PACE, CMS, and state Medicaid policies and claims guidelines.
Develop and implement claims auditing policies and procedures, contributing to the overall effectiveness and accuracy of the claims processing team.
Communicate to and prepare reports for the Claims Manager, Director of Health Plan Operations, VP PACE Business Operations, and PACE Executive Directors.
Support various projects from across the PACE Organizations and community-based program enterprise.
Assist with other duties and projects as assigned.