Provider Audit Specialist

Position Purpose

Prepares for and performs institutional audits to assess appropriate provider billing and to identify any aberrant billings that may have an impact on reimbursement.

Responsible for reviewing all aspects of claim processing to include fraudulent billing practices and to respond to providers on review/audit findings.

Responsible for documenting cost savings related to reviews/audits.

Identifies changes with hospital.

What You’ll Do

• Counsults with providers to determine an agreed upon date that the onsite audit evaluation can be performed, ensuring timely scheduling of the audit.
• Completes and maintains audit files and internal tracking tools for each audit.
• Notifies management of inconsistencies and/or changes in billing practices to rule out possible fraud and abuse.
• Makes recommendations to improve department productivity, cost effectiveness, and timeliness.
• Coordinates with providers to determine an agreed upon date that the onsite audit evaluation can be performed, ensuring timely scheduling of the audit.
• Responds to provider inquiries related to audit findings.
• Requests and analyzes reports on institutional providers to identify claims appropriate to audit after payment of the claim.
• Assists with and provides feedback on department policies/procedures throughout the audit/review processes.

To Qualify For This Position

• For this position, you must have an Associate's degree in a job related field.
• You must have 3 years of clinical nursing and/or medical audit/investigations experience to include 2 years of medical/surgical bedside experience.
• You must have knowledge of anatomy and physiology, disease processes, medical terminology, and patient care practices in order to verify accuracy of medical records.
• You must have the ability to interpret medical records and itemized bills.
• You must have the ability to communicate verbally and in writing to all levels of the organization and externally.
• You must have excellent analytical or critical thinking and problem-solving capabilities with attention to detail.
• You must have the ability to make sound decisions.
• You must have good time management and organizational skills.
• You must have the ability to handle confidential or sensitive information with discretion.
• You must have the ability to make appropriate decisions on claims reviewed/audited in a timely and accurate manner.
• You must have knowledge of hospital and physician audit principles, procedures, and reimbursement.
• You must have the ability to communicate verbally and in writing to all levels of the organization and externally.
• You must have knowledge of hospital and physician audit procedures and requirements.