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Provider Audit Specialist
Location
Pennsylvania
Posted
65 days ago
Salary
$55.1K - $103.8K / year
Seniority
Mid Level
Job Description
Provider Audit Specialist
Capital Blue Cross
• Conduct end-to-end audits of provider charge masters (CDM) and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements. • Review and analyze provider chargemaster data to identify outliers, inconsistencies, or policy violations. • Assist in the development and maintenance of audit models, dashboards, and templates to support enterprise audit functions. • Prepare audit summaries with findings and recommendations. • Support provider communications regarding audit findings and recommend process improvements. • Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards (UB-04, CPT, HCPCS, revenue codes). • Contribute to reimbursement and contract review projects.
Job Requirements
- 2-4 years in provider auditing, revenue integrity, hospital billing, or charge master analysis
- Proficiency in Microsoft Office Suite products (Access, Excel, Word, PowerPoint, etc.), SAS, SQL, PowerBI, or other software used for both analytic, reporting, and data visualization functions.
- Knowledge of CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies.
- Bachelor’s degree in healthcare administration, Health Information Management, Accounting, or related field.
- Preferred certifications: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA).
Benefits
- Professional development opportunities
- Flexible working arrangements
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