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.
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.
Job Summary
The role of auditor 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.
Job Duties:
1.Validate the accuracy and integrity of inpatient and outpatient claims submitted for payment.
2.Perform medical chart reviews to ensure provider billing adherence to medical policies and claims payment policies.
3.Perform Readmission audits to identify related admissions in accordance with claims payment policy criteria.
4.Provide detailed clinical rationale to support and defend Readmission findings.
5.Ensure code assignment is consistent with ICD-10-CM/PCS coding guidelines, AMA CPT guidelines, and clinical validation criteria.
6.Interact with provider to clarify clinical issues, documentation, and billing practices.
7.Initiate, verify, and reconcile claim adjustments. Maintain audit documentation.
8.Evaluate algorithms, review data sets, independently solve problems and research data anomalies. Track audit trends
9.Perform other duties of Auditors as required.
QUALIFICATIONS

• Bachelor's degree in health care related field or business-related discipline preferred.
• Current credentials of RN, or RHIT/RHIA/CCS.
• Strong knowledge of medical terminology and clinical reasoning.
• Strong critical thinking and analytical skills.
• 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).
• Medical Chart Review experience is required.
• Excellent communication skills: verbal and written.
• Intermediate knowledge of MS Office: Excel, Word, Outlook.

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.