American Health Partners Job - 30502931 | CareerArc
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Company: American Health Partners
Location: Franklin, TN
Career Level: Mid-Senior Level
Industries: Healthcare, Pharmaceutical, Biotech

Description

American Health Plans (AHP) owns and operates Institutional Special Needs Plans (I-SNPs) servicing seniors residing in long-term care facilities. In partnership with nursing home operators, the plan offers nursing home residents access to customized, high quality healthcare through specialized Medicare Advantage plans. The Senior Medical Claims Auditor will be responsible for reviewing processed claims prior to payment release and responsible for claim-based projects researching and resolving discrepancies.

Requirements:

• 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.

• Follow all appropriate Federal and State regulatory requirements and guidelines applicable to Health Plan operations or as documented in company policies and procedures

• Work assigned claim projects to completion

• 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 team effort by accomplishing related results as needed

Required Skills:

• Proficient in processing/auditing claims for Medicare and Medicaid plans

• Strong knowledge of CMS requirements regarding claims processing; especially Skilled Nursing Facility and other complex claim processing rules and regulations

• Current experience in both Institutional and Professional claim payment

• Knowledge of health care benefit structures and insurance procedures, as they exist in a Managed Care environment

• Knowledge of automated claims processing systems

• Strong organizational skills; ability to multitask and properly manage time

Required Work Experience:

• 2 years: Complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system

• 2 years: Experience in managed healthcare environment related to claims processing/audit

• 2 years: Knowledge of standard coding and reference materials used in a claim setting, such as CPT4, ICD10, RUGS, PDPM, DRG, APC, HCPC@ and others

• 2 years: Knowledge of CMS requirements regarding claims processing; especially Skilled Nursing Facility and other complex claim processing rules and regulations

• 2 years: Processing/auditing claims for Medicare and Medicaid plans

• 2 years: Experience in managed healthcare environment related to claims processing/audit

• 2 years: Complex claims processing and/or auditing experience in health insurance industry or medical health care delivery system

Licensing/Certification/Education Requirements:

• Coding certification preferred, but not required

Other Requirements:

· Position may require unscheduled overtime, week-end work

· Must be willing and able to work flexible hours

· Travel required


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