Associate Provider Auditor
Bring your drive for excellence, team orientation and customer commitment to Independence Blue Cross; help us renew and reimagine our business and shape the future of health care. Our organization is looking to diversify, grow, innovate and serve, and we are looking for committed, empowered learning-oriented people to join our team. If this describes you, we want to speak with you.
The Associate Provider Auditor addresses provider audit assignments that do not require designations and certifications required of the Provider Auditor in order to identify patterns of provider abuse or fraud in accordance with sound audit methods and practices.
- Identify payment method and factors used in reimbursing targeted claims and apply appropriate audit methods.
- Screen and audit samples in summary and in detail to select claims for audit.
- Examine medical and billing records to identify provider patterns that determine or influence payment.
- Interview provider to clarify clinical issues, documentation and billing practices.
- Document and substantiate billing discrepancies to providers and negotiate resolution.
- Initiate and verify claim adjustments, maintain audit documentation, and prepare statistical data.
- Identify and refer potential provider fraud or abuse to management.
- Work with Provider Network Services to diagnose and correct provider pricing issues.
- Ability to validate the accuracy of claims payments in the legacy (MHS/Planmate) and Highmark systems
- Ability to research provider payment contracts and identify payment impact on auditing process
- Ability to create, update and close SLIQ inquiries
- Ability to create, update and close INSINQ inquiries
- (Extensive) Knowledge of facility and/or Professional pricing
- Knowledge of COB, primacy rules, calculation methodology, Medicare, commercial, workers’ compensation
- Intermediate knowledge of Excel
- Ability to verify member eligibility
- Detail oriented
- Extensive knowledge of provider contracting/ provider payment methodology is required
- Strong written and oral communication and time management skills are required
- Must have demonstrated strong analytical, technical and problem-solving skills
- Bachelor's degree or equivalent work experience required
- 5 years progressive experience in a healthcare-related organization is required, with experience in Provider Networks, Contracting, Claims Processing, or Managed Care Operations strongly preferred
- A/R and revenue cycle experience a plus
- Advanced claim data management, financial systems and database experience a plus
- Effectiveness in maintaining project targets and deadlines
- Works independently on projects, identifies and implements business solutions with minimal supervision
- Strong interpersonal skills and the ability to work in a team environment required
- Working Knowledge of health care provider audit methods, and provider payment methods, clinical aspects of patient care, medical terminology, and medical record / billing documentation.
- Demonstrated analytical skills and interviewing and investigative skills.
Diversity, Equity, and Inclusion
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.
Vaccination Update
This job requires that you demonstrate you have been fully vaccinated for COVID-19 prior to the start of employment, to the extent permitted by law.
About Our Company
Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.
At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!
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.
Agency Disclaimer
All resumes submitted directly to an Independence Blue Cross employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of Independence Blue Cross and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by Independence Blue Cross or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.