Inpatient Hospital Auditor II

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health‑care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families, and we strive to maintain an innovative and inclusive environment that allows our best‑in‑class employees to thrive.

About the Role

This position is responsible for being the lead on site audits of hospital billing and coding practices and desk audits; forms development, profiling and tracking institutional audit trends. Designing audit protocols and special projects. Performs and finalizes multiple per‑diem, bill verification, DRG validation (utilization review audits) and credit balance. Additionally provides guidance and instruction to various stakeholders on ICD‑10‑CM, ICD‑10‑PCS, and DRG assignment payment and auditing.

Responsibilities

• Identifies and presents billing discrepancies found during audit and coordinates referral of improper claim payments through the appropriate channels.
• Identifies error trends related to medical‑record or billing documentation or misinterpretation of provider contract stipulations.
• Compiles statistics and other audit information to present to accounts, regulatory agencies, and internal requesters.
• Reviews and updates audit processes with manager to keep up with new innovations in clinical data review and company cost‑containment initiatives.
• Trains new staff on department and audit procedures.
• Performs other special assignments as requested by manager.
• Demonstrates knowledge, understanding, and conformity to laws, regulations, and policies that pertain to the organizational unit’s business.

Education and Experience

• High School Diploma/GED required.
• Bachelor’s degree in Health Information Management preferred or relevant experience in lieu of degree.
• Minimum of 3 years experience in a medical‑records department of an acute‑care hospital or other health‑care facility.
• Experience with DRG validation, ICD‑10‑CM training and education.

Licensing, Certifications, Registrations

• RHIT/RHIA certification OR RN with CCS knowledge.
• Knowledge of medical terminology, detailed anatomy & physiology, disease pathogenesis and treatment, procedural drug therapies, ancillary and diagnostic services.
• Knowledge of principles of utilization management.
• Knowledge of hospital structures and payment systems.
• Knowledge of Centers of Medicare & Medicaid prospective payment system regulations.
• Prefer knowledge of ACCESS software.

Skills and Abilities

• Effective verbal and written communication skills; ability to work well within a team.
• Ability to deliver highly technical information to less technical individuals.
• Strong PC skills; experience with Microsoft Office (Excel, Word, PowerPoint).
• Professional and ethical business practices; commitment to personal and professional development.
• Proven time‑management; ability to manage multiple priorities, deliver timely and accurate work with a customer‑service focus.
• Ability to work in a production‑focused environment.
• Strong probing and questioning skills to obtain thorough and relevant information.
• Willingness to cross‑train and be cross‑trained in other roles/duties.
• Detail‑oriented with strong organizational and data‑processing skills.
• Ability to follow detailed instructions; strong problem‑solving skills.
• Analytical, research, and problem‑solving abilities.

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. When our people thrive, our communities do too.

Benefits

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement plans
• Generous PTO
• Incentive plans
• Wellness programs
• Paid volunteer time off
• Tuition reimbursement

Pay

Salary Range: $79,100 – $105,945. This range reflects job level and factors such as education, experience, licensure, certifications, geographic location, and internal equity.