Senior Auditor, Payment Integrity

4 weeks ago

Philadelphia, United States Independence Blue Cross Full time

Senior Auditor, Payment Integrity - 240549 DESCRIPTION/RESPONSIBILITIES: The Senior Auditor Payment Integrity will address the most problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters. Claim payment accuracy will be recognized through sound audit review methods and practices, including but not limited to; claim payment evaluation, medical chart review, claim payment data analysis and assessment of established organizational contractual parameters. Provider education and guidance to associates on proper audit and claims accuracy methods. Independently analyzes, extracts, refines, and interprets claims data for actionable insights. Uses self-directed decision making and problem solving that directly impacts financial outcomes and results. Key Responsibilities: * This position will support Payment Integrity and Audit functions * Identify new audit areas by screening and analysis or audit samples * Interact with provider to clarify clinical issues, documentation, and billing practices. * Document and substantiate billing discrepancies to providers and negotiate resolution when appropriate * Initiate and verify claim adjustments, maintain audit documentation, and prepare statistical data * Evaluate complex algorithms, review data sets, independently problem solve and research data anomalies * Provide recommendations and collaborate with payment integrity team on audit outcomes and improved data clarity * Serve as work, technical and project subject expert for internal IBC Audit staff * Trains and guides other associates on data segmentation, payment integrity functional updates and audits * Serve as secondary contact with all operational areas to obtain and maintain policy and general information regarding provider contracting, fee schedules, EDI edits, provider bulletins, and other information relevant to audit decisions * Coordinates claim, reporting and audit systems requiring knowledge and experience in various systems * Communicates autonomously with payment integrity team and management, communicates enhancements, implements system corrections and updates * Identify and refer potential provider fraud or abuse to management * Interpret data, analyze results and opportunities * Develops reports and deliverables for management and communicates with all levels of stakeholders Job Requirements: * Bachelor's degree or equivalent, Master's Preferred * 5+ years of relevant experience, healthcare, payment integrity or health insurance a plus * Intermediate level experience with Excel and other data systems * Good communication skills, analytical skills, Microsoft Office Suite, data visualization * Extensive Knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record / billing documentation * Demonstrated analytical skills and investigative skills * Working Knowledge of project and work management methods and practices related to provider audit * Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes * Ability to interact with business and data management functions * Strong problem-solving skills * Excellent communication skills, both written and verbal Independence has implemented a "Hybrid" model which consists of Associates working in the office 3 days a week (Tuesday, Wednesday & Thursday) and remotely 2 days a week (Monday & Friday). This role is designated as a role that fits into the "Hybrid" model. While associates may work remotely on our designated remote days, the work must be performed in the Tri-State Area of Delaware, New Jersey or Pennsylvania Equal Opportunity Employer-minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity

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