Senior Auditor, Payment Integrity (Remote - PA, NJ, and DE)
Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together, we will achieve our mission to enhance the health and well-being of the people and communities we serve.
We are seeking a Senior Payment Integrity Auditor to lead the most complex and high-risk audit assignments, ensuring claim payment accuracy and compliance with established billing and coding parameters. This role serves as a subject matter expert (SME) for internal audit staff, provides provider education, and mentors associates on proper audit and claims accuracy methods. The Senior Auditor also identifies new audit opportunities, oversees vendor work, and plays a critical role in fraud detection and process improvement.
Responsibilities:
- Address the most problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters.
- Ensure claim payment accuracy through sound audit review methods and practices, including:
- Claim payment evaluation
- Medical chart review
- Claim payment data analysis
- Assessment of organizational contractual parameters
- Claim payment evaluation
- Serve as work, technical, and project subject matter expert for internal IBC audit staff.
- Identify new audit areas through screening and analysis of audit samples.
- Identify and refer potential provider fraud or abuse to management.
- Interact with providers to clarify clinical issues, documentation, and billing practices.
- Document and substantiate billing discrepancies and negotiate resolution when appropriate.
- Initiate and verify claim adjustments, maintain comprehensive audit documentation, and prepare statistical data for leadership reporting.
- Serve as vendor claims processing expert, liaison, or point of contact to ensure successful achievement of vendor deliverables.
- Provide provider education and guidance to associates on proper audit and claims accuracy methods.
- Perform duties of Auditors as required and mentor junior team members.
Qualifications - External
- Education: Bachelor’s degree or equivalent.
- Certifications (Preferred, Not Required):
RHIA, RRA, CCS / CCS-P / CCS-H, ART, CPC, CORT, or RN. - Experience:
- Minimum 5+ years of relevant experience in healthcare auditing, coding, or compliance.
- Minimum 5+ years of relevant experience in healthcare auditing, coding, or compliance.
- Knowledge & Skills:
- Extensive knowledge of healthcare provider audit methods, provider payment methodologies, clinical aspects of patient care, medical terminology, and medical record/billing documentation.
- Demonstrated analytical and investigative skills.
- Working knowledge of project and work management methods and practices related to provider audit.
- Technical Skills:
- Working knowledge of MS Office (Excel, Word, Outlook, SharePoint, Access, etc.).
- SQL or database knowledge a plus.
- Working knowledge of MS Office (Excel, Word, Outlook, SharePoint, Access, etc.).
- Excellent communication, negotiation, and leadership abilities.
- Extensive knowledge of healthcare provider audit methods, provider payment methodologies, clinical aspects of patient care, medical terminology, and medical record/billing documentation.
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.