Auditor focusing on data and AI auditing within MAPFRE. Engaging in global projects and collaborating with international teams.
About the role
- Claims Auditor conducting pre-pay and post-pay audits for Medicare/Medicaid claims. Collaborating with internal/external customers to maintain regulatory compliance and quality standards.
Responsibilities
- 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
Requirements
- 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
- Coding certification preferred
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
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
No Education Requirement
Location requirements
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