Auditor, Payment Integrity
Our organization is looking to diversify, grow, innovate, and serve, and we are looking for committed, empowered, learning-oriented people to join our team. If this describes you, we want to speak with you.
The Payment Integrity Auditor is responsible for conducting complex and high-risk audit assignments to ensure claim payment accuracy and compliance with established billing and coding parameters. This role applies advanced audit methodologies to identify claim overpayments, validate payment integrity, and support organizational goals through detailed analysis and provider engagement.
Responsibilities:
- Address problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters.
- Identify payment methods and factors used in reimbursing targeted claims and apply appropriate audit/payment accuracy methods.
- Evaluate and audit samples in summary and in detail to select audit claims.
- Examine medical and billing records to identify provider patterns that determine or influence payment.
- Interact with providers 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.
- Serve as vendor claims processing lead, liaison, or point of contact to ensure achievement of vendor work.
Qualifications:
Education:
o Bachelor’s degree or equivalent.
Certifications (Preferred, Not Required):
Registered Health Information Administrator (RHIA)
Registered Records Administrator (RRA)
Certified Coding Specialist – Physician/Hospital (CCS / CCS-P / CCS-H)
Accredited Record Technician (ART)
Certified Professional Coder (CPC)
Certified OR Technician (CORT)
Registered Nurse (RN)
Experience:
o Minimum 3 years of relevant experience in healthcare auditing, coding, or compliance.
Knowledge & Skills:
- Working knowledge of healthcare provider audit methods and provider payment methodologies.
- Understanding of clinical aspects of patient care, medical terminology, and medical record/billing documentation.
- Demonstrated analytical and investigative skills.
- Strong proficiency in MS Excel and audit tools.
- Excellent communication and negotiation abilities.
Fully Remote:
This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence’s physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.
IBX is an Equal Opportunity 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.
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.
Vaccination Update
This job requires that you demonstrate you have been fully vaccinated for COVID-19 prior to the start of employment, to the extent permitted by law.
About Our Company
AmeriHealth Casualty has been successfully returning employees to work since 1994, providing quality medical treatment and care and reducing costs for our customers. With our affiliates, we serve more than 1,800 businesses in the area and have offices in Philadelphia, Camp Hill, and Pittsburgh, PA, and Mount Laurel, NJ.
In 1994, CompServices, Inc. began offering workers’ compensation third-party administration services for manufacturers, municipalities, health care facilities, social services, transportation risk, universities, and retail firms. In 1996, AmeriHealth Casualty Insurance Company was established as an extension of our workers’ compensation claims services — its mission to provide workers’ compensation insurance combined with high quality claims service and cost containment.
AmeriHealth Casualty Insurance Company and CompServices write premiums and administer self-insured programs for over 1,800 customers.
Equal Employment Opportunity
AmeriHealth Casualty 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.
Agency Disclaimer
All resumes submitted directly to an AmeriHealth Casualty employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of AmeriHealth Casualty and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by AmeriHealth Casualty or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.