[Hiring] Claims Auditor @SCAN Health Insurance

Role Description

The Claims Auditor will perform various audits of claims payments and denials to ensure accuracy.

• Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials.
• Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of claims processing standards.
• Work assigned cases through SCAN's workflow system, and apply correct status attributes to track and trend issues.
• Notate cases/audits with required detail to ensure that others understand the status of case/audit and final resolutions.
• Work closely with other units within the Claims Department to ensure processing errors are reviewed and corrected prior to final payment.
• Follow policies and procedures to maintain efficient and compliant operations; communicate suggestions for improvement and efficiencies to management.
• Identify and report problems with workflows following proper departmental procedures; actively participate in departmental staff meetings and training sessions.
• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to SCAN Health Plan operations or as documented in company policies and procedures.
• Provide a high level of customer service to internal customers by consistently meeting and/or exceeding team expectations including but not limited to quality, productivity, and attendance.
• Escalate appropriate claims/audit issues to management as required and follow departmental/organizational policies and procedures.
• Maintain required levels of production and quality standards as established by management.
• Participate in and support ad-hoc audits as needed.
• Contribute to overall department success by participating in department initiatives, effective communication and collaboration with all members of the SCAN team.
• Take ownership to identify and report issues to appropriate management staff for resolution.
• Actively support the achievement of SCAN’s Vision and Goals.
• Other duties as assigned.

Qualifications

• Associate’s degree preferred or equivalent experience.
• 3+ years complex claims processing and/or auditing experience with a health plan, healthcare, or managed care organization.
• Proficient in processing/auditing claims for Medicare and Medicaid plans.
• Strong knowledge of CMS requirements regarding claims processing.
• Working knowledge of DOFR (Division of Financial Responsibility), COB (Coordination of Benefits).
• Current experience in 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 through on-the-job training and experience.
• Knowledge of health care benefit structures and insurance procedures, as they exist in a Managed Care environment.
• Knowledge of automated claims processing systems, preferably IKA, and QNXT.

Benefits

• Base wage range: $25.38 to $36.76 per hour.
• Work Mode: Remote.
• Annual bonus program.
• Robust Wellness Program.
• Generous paid-time-off (PTO).
• Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday.
• Excellent 401(k) Retirement Saving Plan with employer match and contribution.
• Robust employee recognition program.
• Tuition reimbursement.
• An opportunity to become part of a team that makes a difference to our members and our community every day!

Company Description

At SCAN, we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.