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Company Contact Info

  • 3250 Mary Street
    Miami, FL 33133
  • Giovanny Flores
  • Phone: 305-448-8100
  • Phone:: 305-489-8006

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Claims Auditor

HealthSun Health Plans • Miami, FL

Posted 6 days ago

Job Snapshot

Travel - None
Experience - At least 2 year(s)
Healthcare - Health Services
Relocation - No


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Job Description

HealthSun Health Plans is seeking energetic,talented and qualified professionals to join us in our mission of changing the healthcare experience of our members - making it easier, friendlier and more accessible.  If you are looking for a challenging and rewarding career with a chance to make a real difference in your community, please apply.

HealthSun Health Plans is headquartered in the Coconut Grove area of Miami, Florida supporting the needs of Medicare Advantage recipients throughout South Florida. We are proud to offer outstanding career advancement opportunities, competitive salaries, paid holidays, medical & dental insurance plans, Paid Time Off, disability benefits, and a 401(k) retirement savings plan.

Responsible for daily auditing of pre and post payment claims to ensure accuracy of claims processing.  This position is the liaison with internal and external clients to resolve provider/member claim issues. 

  • Performs daily audits of claims payments as established in the Claims Department Policies and Procedures.
  • Logs all totals related to claims payment errors and examiner productivity for reporting purposes.
  • Trains claim examiners regarding system and claim procedures.
  • Reviews claims denial letters prior to issuing.
  • Audits check runs and performs check payment process.
  • Runs daily claims report to monitor claims compliance.
  • Manages the HMO claims deduct process. 
  • Tracks and generates request for claims overpayment. 
  • Resolves claims based on Correct Coding edit report to comply with CMS guidelines.
  • Serves as a resource to customer service, Utilization Management and other departments on claim issues.
  • Contributes to a fair and positive work environment by treating peers, superiors, subordinates, clients and vendors with professionalism and respect.
  • Contributes to team effort by accomplishing related results as needed. 
  • Communicates effectively with other professional and support staff in order to achieve positive customer outcomes.
  • Promotes and contributes to a positive, problem-solving environment.
  • Complies with company policies and procedures and maintains confidentiality of medical records in accordance with state and federal laws.
  • Ensures compliance with all HIPAA, OSHA, and other federal, state, and local regulations. 
  • Participates in meetings, training and in-service education, as required. 
  • Performs other duties as assigned.

Job Requirements

  • Minimum of High School diploma or equivalent
  • Minimum of 4 years experience in processing and adjudicating Part A and B Medicare Risk claims required
  • 2+ years of claims audit experience preferred
  • Familiarity with ICD-10, HCPCS, CPT coding, modifiers, APC and DRG pricing, CMS, DMHC regulations, facility and professional claim billing practices  
  • Electronic Data Interchange claims processing experience required
  • Knowledge of Medical terminology
  • Excellent computer knowledge is required, including proficient knowledge of Microsoft Office 
  • Excellent organizational skills
  • Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization
  • Must be able to work with limited supervision
  • Ability to handle multiple functions and prioritize appropriately
  • Ability to meet strict deadlines
  • Ability to work effectively independently and in a team environment
  • Ability to read, analyze, and interpret technical procedures or governmental regulations
  • Ability to write reports, business correspondence, and procedure manuals
  • Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public
  • Ability to calculate figures and amounts, such as discounts, interest, commissions, proportions, percentages, area and volume
  • Ability to define problems, collect data, establish facts, and draw valid conclusions
  • Strong decision-making and analytical skills
  • Must be self-motivated, organized and have excellent prioritization skills
  • Must be able to work well under stressful conditions
  • Must be able to work in a fast paced environment

HealthSun Health Plans and its affiliated companies is an equal opportunity/affirmative action employer and complies with all federal and state laws, regulations and executive orders regarding affirmative action requirements in all programs.M/F/D/V.

HealthSun and its affiliates are also a drug-free workplace.

*Internal candidates must submit the Internal Application Form approved by his/her supervisor before interviewing with HR. Qualified candidates will be considered by the Hiring Manager.

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