Auditor, Zero Balance
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Job Description
Healthcare Auditors developing contract models for analysis and identifying insurance reimbursement issues. Reviewing hospital claim data and related documents in a remote position.
Responsibilities:
- Create and update audit plans, including outlining potential risk areas of a hospital-payer contract based on reimbursement structure and how to manually identify within the data
- Model and create/update pricing documents based on hospital contracts to calculate expected payments with contract language such as percentage of charge, per diems, MSDRG, outlier and/or stoploss, implants, drugs
- Review insurance payments, research applicable sources (contracts, state and federal legislation, insurance payer policies, medical records, etc.) to determine if payment is correct and make recommendations on appropriate next steps
- Identify contractual and clinical risk areas from commercial and government payors (e.g., Medicare, Medicaid)
- Conduct review of zero-balance hospital accounts to identify underpaid inpatient claims
- Present clear documentation of process, findings, and results of audits
- Make recommendations to improve internal processes and external client contracts/processes
- Work with data analyst team to build and validate pricing models
- Other duties as assigned
Requirements:
- High School Diploma or equivalent required
- Minimum of 2 years of experience working with large sets of (healthcare) data
- Minimum of 2 years of experience in areas of research and analysis
- Minimum of 2 years of experience with managed care contracts (government and commercial) and hospital reimbursement
- Minimum of 2 years of experience working with inpatient claims
- Minimum of 1 year of experience with contract modeling
- Basic Excel skills, including knowledge of simple formulas (SUM, AVERAGE), basic pivot tables and ability to filter and sort data sets
- Strong verbal and written communication skills
- Ability to translate complex contract language and healthcare data into actionable information and insights
- Ability to work independently to solve problems and recommend technical solutions (ex. provide calculation/formula to price)
- Strong organization skills and attention to detail
Benefits:
- We seek to create an environment that cultivates your professional development and personal growth
- We build long-term careers by investing in YOU
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