Auditor, Payment Integrity (Finance)

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 role of Auditor, Payment Integrity will 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.  Provide education and guidance to associates on proper audit and claim accuracy methods.

Description:

·         Validate the accuracy and integrity of inpatient and outpatient claims submitted for payment.

·         Perform medical chart reviews to ensure provider billing adherence to medical policies and claims payment policies. 

·         Perform Readmission audits to identify related admissions per claims payment policy criteria. 

·         Provide a detailed clinical rationale to support Readmission findings. 

·         Ensure code assignment is consistent with ICD-10-CM/PCS coding guidelines, AMA CPT guidelines, and clinical validation criteria. 

·         Interact with providers to clarify clinical issues, documentation, and billing practices.

·         Initiate, verify, and reconcile claim adjustments.  Maintain audit documentation.

·         Evaluate algorithms, review data sets, independently solve problems, and research data anomalies.  Track audit trends

·         Perform other duties of Auditors as required.

Qualifications:

·         Bachelor's degree in Nursing, Health Information Management (HIM), or healthcare-related field.

·         Current credentials of RN, CPC, or RHIT/RHIA/CCS.

·         Strong knowledge of Medical Terminology.

·         Knowledge of ICD-10-CM and ICD-10-PCS coding guidelines.

·         Understanding of Inpatient Prospective Payment System (IPPS), MSDRG, and regulatory requirements and/or Outpatient Prospective Payment System (OPPS).

·         Understanding of CPT-modifiers impact on payment determination preferred.

·         Medical Chart Review experience is required.   

·         Excellent communication skills: verbal and written.

·         Intermediate knowledge of MS Office, Excel, Word, and Outlook

Hybrid:

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.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app