Capital Blue Cross ยท 1 day ago
Senior Provider Audit Specialist
Harrisburg, PA
Full-time
Onsite
Senior Level
5+ years expCapital Blue Cross is committed to improving the health and well-being of its members and communities. The Senior Provider Audit Specialist leads complex audits of hospital billing practices, ensuring financial integrity and compliance while mentoring team members and developing audit strategies.
ConsultingHealth CareHealth InsuranceProfessional Services
Responsibilities
Lead 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
Design and enhance audit models, dashboards, and templates to support enterprise audit functions
Present high-level findings to executive leadership and support provider negotiation efforts
Support provider outreach efforts to address audit findings and recommend process improvements
Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards (UB-04, CPT, HCPCS, revenue codes
Recommend process improvements, charge containment strategies, and policy changes to ensure appropriate billing and reimbursement practices
Participate in projects related to reimbursement policy development, provider contract review, and audit compliance
Drive proactive analytical studies to assess changes in provider billing patterns, charge description masters and other variable reimbursement provisions
Mentor junior auditors and help establish best practices for audit execution
Qualification
Required
Lead 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
Design and enhance audit models, dashboards, and templates to support enterprise audit functions
Present high-level findings to executive leadership and support provider negotiation efforts
Support provider outreach efforts to address audit findings and recommend process improvements
Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards (UB-04, CPT, HCPCS, revenue codes
Recommend process improvements, charge containment strategies, and policy changes to ensure appropriate billing and reimbursement practices
Participate in projects related to reimbursement policy development, provider contract review, and audit compliance
Drive proactive analytical studies to assess changes in provider billing patterns, charge description masters and other variable reimbursement provisions
Mentor junior auditors and help establish best practices for audit execution
Knowledge of hospital CDMs, UB-04 billing, CPT/HCPCS codes, and revenue cycle operations
Advanced experience with Microsoft Office Suite products (Access, Excel, Word, PowerPoint, etc.), SAS, SQL, PowerBI, or other software used for both analytic, reporting, and data visualization functions
Familiarity with CMS billing guidelines, DRG/APC reimbursement, and hospital pricing regulations
Minimum of 5 years in provider auditing, revenue integrity, hospital billing, or charge master analysis
Experience with Commercial and Medicare Advantage plans
Experience with payer-side claim auditing, payment policy, or charge validation
Excellent communication and reporting skills, with experience presenting findings to executive stakeholders
Expertise in CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies
Bachelor's degree in healthcare administration, Health Information Management, Accounting, or related field
Preferred
Master's preferred
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
Company
Capital Blue Cross
At Capital Blue Cross, we promise to go the extra mile for our team and our community.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Glenn Heisey
Executive Vice President and Chief Operating Office
Recent News
2025-10-02
2022-10-14
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