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Capital Blue Cross · 4 months ago

Senior Provider Audit Specialist

United States

Full-time

Remote

Senior Level

5+ years exp

Capital Blue Cross is dedicated to improving the health and well-being of its members and communities. The Senior Provider Audit Specialist leads complex audits of hospital billing practices to ensure financial integrity and compliance, while mentoring team members and shaping audit strategy.

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

Provider auditingCPT/HCPCS codingCMS billing guidelinesMicrosoft Office SuiteSQLPowerBIProcess improvementData visualizationHealthcare administrationHealth Information ManagementAccountingCharge master analysisCommunicationReporting skillsMentoring

Required

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

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

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