Provider Auditor
Corporate and Financial Investigations Department (CFID) is responsible for the detection and investigation of all potential areas of fraud, waste and abuse against IBC Family of Companies. The CFID Support Group's goal is to assist the Corporate and Financial Investigations Department by accumulating information to support fraud, waste and abuse investigations, and provider audits, by creating trend analysis across all IBC lines of business. CFID Support gathers and evaluates information from a variety of data collection sources for fraud, abuse, audit and questionable billing patterns and trends.
The DRG Auditor is responsible for the auditing of inpatient medical records to validate the admit order, assignment and sequencing of ICD 10-CM diagnosis and procedure codes, discharge status codes, and DRG assignment and other types of audits. The auditor would be responsible to provide a detailed rationale for each medical record review that resulted in a DRG change including supporting references.
Responsibilities may include:
- Audit claims to validate DRG assignment
- Manually screen data files to identify claims for audit
- Write DRG dispute letters citing references and clear clinical rationale to support the dispute
- Identify patterns of provider billing abuse or fraudulent cases.
- Perform audits that involve verifying charges, coding, and identifying ineligible benefits, and other elements as applicable.
- Analyze, verify, and adjust provider billing based primarily through independent field and desk reviews of provider medical and billing records.
- Work closely with analysts, auditors, and investigators in CFID.
- Bachelor’s degree in health care related field or business related discipline
- Possesses current AHIMA credentials (RHIT/RHIA/CCS), CCS preferred
- In lieu of bachelor’s degree, a candidate possessing RHIA/RHIT or CCS credential will be considered with 5 to 7 years of inpatient coding experience
- Demonstrate extensive knowledge of ICD-10-CM coding and DRG reimbursement, with a minimum of three years of inpatient coding experience
- Excellent prioritization and organizational skills
ADDITIONAL INFORMATION
- Possess strong data analysis skills
- Ability to work independently.
- Strong computer skills required
- Excellent communication skills and must be detailed oriented.
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.