Job Description
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description
This role involves conducting audits and ensuring compliance in claims processing for Medicare and Medicaid plans. • 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 closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment • Work assigned claim projects to completion • Provide a high level of customer service to internal and external customers; achieve quality and productivity goals • Escalate appropriate claims/audit issues to management as required; follow departmental/organizational policies and procedures • Maintain production and quality standards as established by management • Participate in and support ad-hoc audits as needed • Other duties as assigned Qualifications • Two (2) years’ experience with complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system • Two (2) years’ experience in managed healthcare environment related to claims processing/audit • Two (2) years’ experience with standard coding and reference materials used in a claim setting, such as CPT4, ICD10 and HCPCS • Two (2) years’ experience with CMS requirements regarding claims processing; especially Skilled Nursing Facility and other complex claim processing rules and regulations • Two (2) years’ experience processing/auditing claims for Medicare and Medicaid plans Requirements • Proficient in processing/auditing claims for Medicare and Medicaid plans • Strong knowledge of CMS requirements regarding claims processing, especially regarding skilled nursing facilities and other complex claim processing rules and regulations • Current experience with both Institutional and
Professional claim payments • Knowledge of automated claims processing systems • Hybrid role that may require 2-3 days per week onsite at the Franklin, TN office Benefits • Affordable Medical/Dental/Vision insurance options • Generous paid time-off program and paid holidays for full time staff • TeleMedicine 24/7/365 access to doctors • Optional short- and long-term disability plans • Employee Assistance Plan (EAP) • 401K retirement accounts • Employee Referral Bonus Program Company Description American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc.
owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside 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. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Louisiana, Iowa, and Idaho with planned expansion into other states in 2024. Apply tot his job