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Senior Provider Audit Specialist

IT SupportIT SupportFull TimeRemoteSeniorTeam 1,001-5,000Since 1938H1B SponsorCompany SiteLinkedIn

Location

Pennsylvania

Posted

61 days ago

Salary

$72.9K - $137.3K / year

Seniority

Senior

Bachelor Degree5 yrs expEnglishSQL

Job Description

Senior Provider Audit Specialist

Capital Blue Cross

• Lead end-to-end audits of provider charge masters, billing practices, and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements • Design and enhance audit frameworks, models, dashboards, and templates that standardize audit execution and support enterprise provider audit functions • Evaluate audit findings and exercise professional judgement to determine materiality, recovery potential and recommended resolution strategies • Lead or support provider discussions related to audit findings, including explaining methodologies, defending determinations, and recommending corrective actions or process improvements • Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards • Recommend process improvements, charge containment strategies, and policy changes to ensure appropriate billing and reimbursement practices • Drive proactive analytical studies to assess changes in provider billing patterns, charge description masters and other variable reimbursement provisions • Provide technical guidance, mentoring, and quality oversight to Provider Audit Specialists

Job Requirements

  • Minimum of five (5) years of progressive experience conducting provider billing, reimbursement, or payment integrity audits
  • Expertise in CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies
  • Advanced experience with Microsoft Office Suite products (Access, Excel, Word, PowerPoint), SAS, SQL, Power BI, or other software used for analytic, reporting, and data visualization functions
  • 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

  • Medical, Dental & Vision coverage
  • Retirement Plan
  • Generous time off including Paid Time Off
  • Holidays
  • Volunteer time off
  • Incentive Plan
  • Tuition Reimbursement
  • Flexible environment

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The requirements listed below are representative of the knowledge, skill, and/or ability required. - High school diploma or GED required - 1–2 years of IT Service/Help Desk or technical support experience - CompTIA A+ certification or equivalent experience preferred - Strong customer service and communication skills - Stable power and broadband internet connection COMPETENCIES - Technical Skills - Working knowledge of Windows, Android and iOS operating systems, desktop/laptop hardware, printers, and peripherals - Basic understanding of LAN/WAN, internet connectivity, VPN, and remote access tools - Proficiency with Microsoft Office and common business applications - Familiarity with ticketing systems and ITIL-based processes - Problem Solving & Analysis - Identifies issues, evaluates information objectively, and applies appropriate solutions - Recognizes recurring issues and contributes ideas for prevention or improvement - Documents findings clearly and accurately - Communication - Communicates clearly and professionally with both technical and non-technical users - Explains technical concepts in an audience-appropriate manner - Demonstrates effective listening, empathy, and urgency - Customer Focus - Anticipates user needs and delivers timely, high-quality support - Maintains a positive and service-oriented attitude, even in challenging situations - Adaptability & Learning - Embraces change and new technologies with a positive mindset - Seeks feedback and applies it constructively - Demonstrates a continuous learning mindset - Accountability & Results - Manages time effectively and meets commitments - Takes initiative and follows through on assigned work - Adheres to policies, procedures, and best practices - Professionalism & Integrity - Acts with honesty, reliability, and respect - Treats all users fairly and consistently - Handles difficult conversations professionally and respectfully WORK ENVIRONMENT / PHYSICAL ACTIVITY The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. 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Please do not send resumes to this email address - it is intended only be used to provide a notice of non-compliance. Please note that due to the volume of applications received, we are unable to respond to individual inquiries about the status of your application.

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