Provider Audit Specialist

🕒 July 6

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $57k - $105.9k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 43%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Capital Blue Cross

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1938

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

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.

📋 Description

• Conduct end-to-end audits of provider chargemasters and associated claims • 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 developing and maintaining audit models, dashboards, and templates • Prepare audit summaries with findings and recommendations • Support provider communications regarding audit findings • Recommend process improvements • Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards, including UB-04, CPT, HCPCS, and revenue codes • Contribute to reimbursement and contract review projects • Collaborate with internal teams to recommend improvements and support financial recoveries

🎯 Requirements

• Proficiency in Microsoft Office Suite products, including Access, Excel, Word, and PowerPoint • Proficiency in SAS, SQL, Power BI, or other software used for analytics, reporting, and data visualization • 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 • 2–4 years in provider auditing, revenue integrity, hospital billing, or chargemaster analysis • Experience with Commercial and Medicare Advantage plans • Experience with payer-side claim auditing, payment policy, or charge validation • 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

• Flexible work environment • Health and wellbeing prioritized • Supportive colleagues • Volunteer opportunities in the community • Training and continuing education • Professional and personal growth investment