We are seeking a Claims Auditor to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.
The Claims Auditor plays an essential role in ensuring the accuracy, compliance, and integrity of health care claims within the organization. This position involves conducting thorough audits of submitted claims to verify adherence to regulatory standards, contractual obligations, and internal policies. The Claims Auditor will identify discrepancies, potential fraud, and areas for process improvement, thereby safeguarding the organization's financial health and reputation. By collaborating with claims processors, healthcare providers, and compliance teams, the auditor helps to streamline claims management and reduce errors. Ultimately, this role supports the delivery of efficient and ethical services by maintaining transparent and accountable claims operations.
Minimum Qualifications:
- Bachelor’s degree in Health Administration, or a related field.
- At least 2 years of experience in claims auditing, health care compliance, or a similar role within the health care industry.
- Strong knowledge of health care claims processes, insurance billing, and regulatory requirements such as HIPAA and CMS guidelines.
- Proficiency in audit software and Microsoft Office Suite, particularly Excel for data analysis.
- Relevant experience may substitute for the educational requirement on a year-for-year basis.
Preferred Qualifications:
- Master’s degree in Health Administration, or a related field.
- Certification such as Certified Internal Auditor (CIA), Certified Professional Coder (CPC), or Certified Healthcare Auditor (CHA).
- Experience with claims management software.
- Familiarity with fraud detection techniques and health care fraud prevention programs.
- Demonstrated ability to lead audit projects or mentor junior auditors.
Responsibilities:
- Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
- Conduct detailed audits of healthcare claims to ensure accuracy, compliance with regulations, and adherence to organizational policies.
- Analyze claim data and documentation to identify errors, inconsistencies, or potential fraud.
- Prepare comprehensive audit reports with findings, recommendations, and corrective actions for management and stakeholders.
- Collaborate with claims teams and healthcare providers to resolve discrepancies and drive process improvements.
- Stay updated on healthcare regulations and industry best practices, while supporting internal and external audits with relevant documentation and insights.
- Perform other duties as assigned.
Skills Required
- Bachelor's degree in Health Administration or related field (or equivalent experience year-for-year)
- At least 2 years of experience in claims auditing, health care compliance, or similar healthcare role
- Strong knowledge of health care claims processes, insurance billing, HIPAA, and CMS guidelines
- Proficiency in audit software and Microsoft Office Suite, particularly Excel for data analysis
- Master's degree in Health Administration or related field
- Certification such as CIA, CPC, or CHA
- Experience with claims management software
- Familiarity with fraud detection techniques and healthcare fraud prevention programs
- Demonstrated ability to lead audit projects or mentor junior auditors
What We Do
Independent Living Systems, LLC, offers a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid and Dual-Eligible Market. Independent Living Systems has been an industry leader in managing home and community-based programs for over 16 years. Leveraging ILS’ award winning technology platform, ILS provides assistance beyond the clinical realm at every stage of care from hospitalization to the treatment of chronic illnesses to personalized care management including nutritional support. As one of the country’s leading providers of Nutritional Support Services and medically tailored meals, ILS provides nutrition counseling and home delivered meals for individuals transitioning from acute settings to the home as well as for those combatting the effects of one or more chronic diseases. In partnership with health plans, providers, hospitals, and pharmaceutical and medical device companies, ILS provides solutions aimed at improving health outcomes while rebalancing costs. ILS’ suite of products and services include: MLTSS - Managed Long-Term Services Supports Suite of solutions including assessments, care management, and coordination of home and community-based services, care planning, and back-office support CCM - Comprehensive Care Management A streamlined solution for ongoing care management and care optimization targeted towards special needs populations and special needs plans Meals and Nutrition One of the nation’s largest nutritional providers delivering consistent, high-quality therapeutic meals to elderly and at-risk populations TPA – Third Party Administration A fully integrated business and technology offering to support all administrative and financial reporting requirements of health plans and risk bearing entities MSO – Management Services Organization Population and provider-based interventions to address utilization and monitor unit costs of services For more information please contact us via email at [email protected].
