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Independence Blue Cross · 1 month ago

Senior Auditor, Payment Integrity (Remote - PA, NJ, and DE)

United States

Full-time

Remote

Senior Level

5+ years exp

Independence Blue Cross is focused on renewing and reimagining the future of health care. They are seeking a Senior Payment Integrity Auditor to lead complex audit assignments, ensuring claim payment accuracy and compliance while serving as a subject matter expert for internal audit staff.

Health CareHealth InsuranceInsuranceMedical

Responsibilities

Address the most problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters

Ensure claim payment accuracy through sound audit review methods and practices, including:

Claim payment evaluation

Medical chart review

Claim payment data analysis

Assessment of organizational contractual parameters

Serve as work, technical, and project subject matter expert for internal IBC audit staff

Identify new audit areas through screening and analysis of audit samples

Identify and refer potential provider fraud or abuse to management

Interact with providers to clarify clinical issues, documentation, and billing practices

Document and substantiate billing discrepancies and negotiate resolution when appropriate

Initiate and verify claim adjustments, maintain comprehensive audit documentation, and prepare statistical data for leadership reporting

Serve as vendor claims processing expert, liaison, or point of contact to ensure successful achievement of vendor deliverables

Provide provider education and guidance to associates on proper audit and claims accuracy methods

Perform duties of Auditors as required and mentor junior team members

Qualification

Healthcare auditingProvider payment methodologiesAnalytical skillsMedical terminologyMS OfficeProject managementNegotiation skillsLeadership abilities

Required

Bachelor's degree or equivalent

Minimum 5+ years of relevant experience in healthcare auditing, coding, or compliance

Extensive knowledge of healthcare provider audit methods, provider payment methodologies, clinical aspects of patient care, medical terminology, and medical record/billing documentation

Demonstrated analytical and investigative skills

Working knowledge of project and work management methods and practices related to provider audit

Working knowledge of MS Office (Excel, Word, Outlook, SharePoint, Access, etc.)

Excellent communication, negotiation, and leadership abilities