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.
Inclusion and Belonging
At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
About Our Company
Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.
At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!
Equal Employment Opportunity
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.
Agency Disclaimer
All resumes submitted directly to an Independence Blue Cross 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 Independence Blue Cross and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by Independence Blue Cross or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.