Auditor, Payment Integrity (Pharmacy)
Our organization is looking for dynamic individuals who love to learn, thrive on innovation, and are open to exploring new ways to achieve our goals. If this describes you, we want to speak with you. You can help us achieve our vision to lead nationally in innovating equitable whole-person health.
The Auditor Payment Integrity audits claims submitted to IBX to verify accuracy of provider payments and charges.
Responsibilities includes:
· Identify patterns of provider billing for fraud, waste, or abuse.
· Audits encompass identification of inappropriate billing through daily reviews, live audits, and desk audits.
· This function also includes analysis, verification and adjustment of provider billing based primarily on desk reviews or provider medical billing records in close conjunction with CFID audit analysis, auditors, and investigators.
· Address the usual and customary Provider Audit assignments to identify patterns of provider abuse or fraud in accordance with sound audit methods and practices.
· Screen and audit samples in summary and in detail to select claims for audit. Initiate and verify claim adjustments, maintain audit documentation, and prepare statistical data.
· Identify and refer potential provider fraud or abuse to management. Identify and participate in development and implementation of new audit functions.
· Provide work guidance to lower-level Provider Auditors.
QUALIFICATIONS:
· Provide work guidance to lower-level Provider Auditors.
· Certified Pharmacy Technician (CPhT) required.
· Certified Pharmacy Tech for Pharmacy Audit.
· Four (4) or more years’ experience which includes two (2) or more of health care Provider Audit experience and may include two (2) or more years of health care Claims or Customer Service experience.
· Extensive Knowledge of health care provider audit methods and medical terminology. Demonstrated analytical skills, interviewing and investigative skills.
· Working Knowledge of MS Office, Excel, Word, Outlook, SharePoint, Outlook, Access, etc.
Independence has implemented a “Hybrid” model which consists of Associates working in the office 3 days a week (Tuesday, Wednesday & Thursday) and remotely 2 days a week (Monday & Friday). This role is designated as a role that fits into the “Hybrid” model. While associates may work remotely on our designated remote days, the work must be performed in the Tri-State Area of Delaware, New Jersey or Pennsylvania
Independence Blue Cross 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.
Diversity, Equity, and Inclusion
At Independence, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that 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. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the 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
Independence Blue Cross 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 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.