Summary Responsible for providing a full range of financial, compliance, and operational audits, business advisory and consultation services, investigations, internal controls, accountability, and use of resources. Description This is a full time remote position working 40 hours per week. What You'll Do: - Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities of the corporation including evaluation of internal controls. Identifies, documents, and evaluates business risks. Documents issues, the causes of those issues, and their effects on the process/function and the corporation. - Drafts recommendations to limit risks and improve processes, functions and activities. Writes audit reports for corporate executive management that clearly and effectively convey engagement evaluations, conclusions, and recommendations. Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance with laws, regulations, and management policies. Conducts testing of corrective actions as identified. - Develops detailed reports on each audit conducted. Reports include a review of findings and an identification of recommendation to correct any deficiencies and methods for improvement to processes. Examines and evaluates financial and information systems, recommending controls to ensure system reliability and data integrity. - Conducts special audit studies for management, such as those required to discover controls for prevention of fraud. Prepares reports of findings and recommendations for management. - Assists other auditors in completing their assignments as a means of maximizing audit efficiency and thus reducing lost time and involvement of corporate personnel. Required Education: Bachelor's in a job related field. Degree Equivalency: 4 years job related work experience or Associate's and 2 years job related work experience. Required Work Experience: 2 years auditing experience. Required Skills and Abilities: - Knowledge of the principles and practices of auditing. - Ability to analyze and determine the applicability of financial data. - Ability to draw conclusions and make appropriate recommendations for analyzed data. - Ability to gather information by examining records and documents and interviewing individuals. - Strong interpersonal skills. - Ability to maintain effective working relationships. - Ability to communicate clearly and effectively in oral and written form. - Ability to handle sensitive matters on a confidential basis. Required Software and Tools: Microsoft Office. Preferred Licenses and Certificates: Certified Internal Auditor (CIA) or Certified Public Accountant (CPA) or Certified Information Systems Auditor (CISA) or Certified Fraud Examiner (CFE). Work Environment: Typical office environment. Travel between office buildings may be required. Out of town travel may be required. Our Comprehensive Benefits Package Includes The Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits at the first of the month following 28 days of employment: - Subsidized health plans, dental and vision coverage - 401k retirement savings plan with company match - Life Insurance - Paid Time Off (PTO) - On-site cafeterias and fitness centers in major locations - Education Assistance - Service Recognition - National discounts to movies, theaters, zoos, theme parks and more What We Can Do for You: We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company. What To Expect Next: After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. Salary Range: Range Minimum $53,320.00 Range Midpoint $77,519.00 Range Maximum $101,718.00 Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.

• Review medical records to verify services were provided as billed for Hospital Bill Audit reviews. • Identify overcharges, undercharges and unbundled items. • Identify unbundled items on the itemized bill specific to payer Unbundling Guidelines and provide references and rationale to support review findings. • Onsite Travel – Maintain timely communication with Audit Coordinator regarding scheduling, completion and submission of audits. Abide by the EXL Travel policy while making travel arrangements for onsite audits. • Scheduling Audits: Manage inventory and schedule audits timely by contacting the provider to schedule date and time to perform audits. • Report any problems in the audit process to Manager for resolution. • Comply with HIPAA and other regulations regarding the confidentiality of patient information. • Conduct all job functions and responsibilities in accordance with all company Compliance, Information Security and Regulatory policies, procedures and programs.

• Review inpatient medical records to verify that the DRG (Diagnosis-Related Group) code makes sense based on the documentation. • Apply clinical and coding knowledge to spot inaccuracies and identify potential overpayments. • Document your findings in clear, professional language that explains the rationale behind your review. • Use industry tools like 3M or Webstrat to support your decisions. • Work independently while meeting productivity and quality goals. • Stay up to date with clinical guidelines, DRG rules, and industry trends.

• Apply your expert knowledge of billing HCD claims to perform extensive audit reviews. • Utilize HCPCS codes, medical record review, industry and EXL proprietary tools in the audit process. • Write professional communications documenting audit findings and supporting rationales. • Apply your extensive industry knowledge to identify audit trends and opportunities. • Conduct HCPCS coding reviews to verify the accuracy of the coding assignment and reimbursement on high cost drug professional and outpatient facility claims. • Apply complex medical record reviews to identify discrepancies between physician orders, nursing administration logs, and final claims submissions. • Apply Medicare, Medicaid, and commercial guidelines to a variety of claim scenarios and effectively utilize industry and proprietary tools to maximize overpayment identifications. • Document audit results in a clear, concise, and effective manner using AMA Guidelines. • Utilize proprietary workflow systems to make audit determinations, generate audit rationales, and move claims through workflow process correctly efficiently and accurately. • Accurately reprice complex claims utilizing multiple client claims systems. • Meet or exceed EXL established program productivity and quality goals, including uphold rate for appeals. • Research prescribed drug dosage and related conditions to ensure appropriateness of medical guidelines and accuracy of reimbursement. • Comply with all EXL policies and procedures including HIPAA and other state and federal regulations.