Provider Audit Specialist

Yesterday

🔔 Pennsylvania – Remote

Although this job is listed in Pennsylvania, this company may be open to hiring remote in other states.

💵 $55.1k - $103.8k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

💻 IT Support

🦅 H1B Visa Sponsor

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Capital Blue Cross

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Healthcare Insurance • Finance • B2C

Capital Blue Cross is a health insurance company that offers a range of health plans for individuals, families, and employers. They serve customers in Central Pennsylvania and the Lehigh Valley, focusing on providing health coverage services such as Medicare plans, student health plans, and resources for managing medical care. Capital Blue Cross positions itself as a partner in health, emphasizing support for members' overall wellness and preventive health measures.

1001 - 5000 employees

Founded 1938

⚕️ Healthcare Insurance

💸 Finance

👥 B2C

📋 Description

• 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

🎯 Requirements

• 2-4 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 • 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 • Knowledge of hospital CDMs, UB-04 billing, CPT/HCPCS codes, and revenue cycle operations • Familiarity with CMS billing guidelines, DRG/APC reimbursement, and hospital pricing regulations • 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 • More