Provider Audit Specialist
Capital Blue Cross · Harrisburg, PA · 3 wk ago
RemoteRemoteFull-time
Duties and Responsibilities
- Conduct end-to-end audits of provider charge masters (CDM) and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements.
- Review and analyze provider chargemaster data to identify outliers, inconsistencies, or policy violations.
- Assist in the development and maintenance of audit models, dashboards, and templates to support enterprise audit functions.
- Prepare audit summaries with findings and recommendations.
- Support provider communications regarding audit findings and recommend process improvements.
- Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards (UB-04, CPT, HCPCS, revenue codes).
- Contribute to reimbursement and contract review projects.
Skills
- Proficiency in Microsoft Office Suite products (Access, Excel, Word, PowerPoint, etc.), SAS, SQL, PowerBI, or other software used for both analytic, reporting, and data visualization functions.
Knowledge
- Knowledge of CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies.
- Knowledge of hospital CDMs, UB-04 billing, CPT/HCPCS codes, and revenue cycle operations.
- Familiarity with CMS billing guidelines, DRG/APC reimbursement, and hospital pricing regulations.
Experience
- 2-4 years in provider auditing, revenue integrity, hospital billing, or charge master analysis.
- Experience with Commercial and Medicare Advantage plans.
- Experience with payer-side claim auditing, payment policy, or charge validation.
Education and Certifications
- Bachelor’s degree in healthcare administration, Health Information Management, Accounting, or related field.
- Preferred certifications: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA).
Benefits
- Comprehensive benefits package including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.