Auditor, Payment Integrity

4 weeks ago

Philadelphia, United States Independence Blue Cross Full time

Our organization is looking for dynamic individuals who love to learn, thrive on innovation, and are open to exploring new ways to achieve our goals. If this describes you, we want to speak with you. You can help us achieve our vision to lead nationally in innovating equitable whole-person health.

The Auditor Payment Integrity audits claims submitted to IBX to verify accuracy of provider payments and charges.

Responsibilities includes:

• Identify patterns of provider billing for fraud, waste, or abuse.

• Audits encompass identification of inappropriate billing through daily reviews, live audits, and desk audits.

• This function also includes analysis, verification and adjustment of provider billing based primarily on desk reviews or provider medical billing records in close conjunction with CFID audit analysis, auditors, and investigators.

• Address the usual and customary Provider Audit assignments to identify patterns of provider abuse or fraud in accordance with sound audit methods and practices.

• Screen and audit samples in summary and in detail to select claims for audit. Initiate and verify claim adjustments, maintain audit documentation, and prepare statistical data.

• Identify and refer potential provider fraud or abuse to management. Identify and participate in development and implementation of new audit functions.

• Provide work guidance to lower-level Provider Auditors.

QUALIFICATIONS:

• Provide work guidance to lower-level Provider Auditors.

• Certified Pharmacy Technician (CPhT) required.

• Certified Pharmacy Tech for Pharmacy Audit.

• Four (4) or more years' experience which includes two (2) or more of health care Provider Audit experience and may include two (2) or more years of health care Claims or Customer Service experience.

• Extensive Knowledge of health care provider audit methods and medical terminology. Demonstrated analytical skills, interviewing and investigative skills.

• Working Knowledge of MS Office, Excel, Word, Outlook, SharePoint, Outlook, Access, etc.

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 Employment Opportunity

Independence Blue Cross is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

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