Senior Auditor, Payment Integrity
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 Senior Auditor Payment Integrity will address the most problematic and complex audit assignments to identify claim overpayments in accordance with established billing and coding parameters. Claim payment accuracy will be recognized through sound audit review methods and practices, including but not limited to; claim payment evaluation, medical chart review, claim payment data analysis and assessment of established organizational contractual parameters. Provider education and guidance to associates on proper audit and claims accuracy methods. Independently analyzes, extracts, refines, and interprets claims data for actionable insights. Uses self-directed decision making and problem solving that directly impacts financial outcomes and results.
- This position will support Payment Integrity and Audit functions
- Identify new audit areas by screening and analysis or audit samples
- Interact with provider 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
- Evaluate complex algorithms, review data sets, independently problem solve and research data anomalies
- Provide recommendations and collaborate with payment integrity team on audit outcomes and improved data clarity
- Serve as work, technical and project subject expert for internal IBC Audit staff
- Trains and guides other associates on data segmentation, payment integrity functional updates and audits
- Serve as secondary contact with all operational areas to obtain and maintain policy and general information regarding provider contracting, fee schedules, EDI edits, provider bulletins, and other information relevant to audit decisions
- Coordinates claim, reporting and audit systems requiring knowledge and experience in various systems
- Communicates autonomously with payment integrity team and management, communicates enhancements, implements system corrections and updates
- Identify and refer potential provider fraud or abuse to management
- Interpret data, analyze results and opportunities
- Develops reports and deliverables for management and communicates with all levels of stakeholders
Job Requirements:
- Bachelor's degree or equivalent, Master's Preferred
- 5+ years of relevant experience, healthcare, payment integrity or health insurance a plus
- Intermediate level experience with Excel and other data systems
- Good communication skills, analytical skills, Microsoft Office Suite, data visualization
- Extensive Knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record / billing documentation
- Demonstrated analytical skills and investigative skills
- Working Knowledge of project and work management methods and practices related to provider audit
- Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes
- Ability to interact with business and data management functions
- Strong problem-solving skills
- Excellent communication skills, both written and verbal
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.