Senior Provider Audit Specialist
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Job Description
Lead complex, high-impact audits of hospital billing and reimbursement practices at Capital Blue Cross. Drive financial integrity and compliance across the organization by developing audit strategies and mentoring team members.
Responsibilities:
- Lead end-to-end audits of provider charge masters, billing practices, and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements
- Design and enhance audit frameworks, models, dashboards, and templates that standardize audit execution and support enterprise provider audit functions
- Evaluate audit findings and exercise professional judgement to determine materiality, recovery potential and recommended resolution strategies
- Lead or support provider discussions related to audit findings, including explaining methodologies, defending determinations, and recommending corrective actions or process improvements
- Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards
- Recommend process improvements, charge containment strategies, and policy changes to ensure appropriate billing and reimbursement practices
- Drive proactive analytical studies to assess changes in provider billing patterns, charge description masters and other variable reimbursement provisions
- Provide technical guidance, mentoring, and quality oversight to Provider Audit Specialists
Requirements:
- Minimum of five (5) years of progressive experience conducting provider billing, reimbursement, or payment integrity audits
- Expertise in CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies
- Advanced experience with Microsoft Office Suite products (Access, Excel, Word, PowerPoint), SAS, SQL, Power BI, or other software used for analytic, reporting, and data visualization functions
- 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
- Flexible environment
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