About this role
This senior role conducts on-site reviews of medical records, itemized bills, and provider contracts to ensure claims are paid according to contracts and reimbursement policies. The auditor verifies claim dollar amounts in the claims system, identifies billing aberrations and potential abuse, and drafts reports requesting payment adjustments for overpayments.
Key Responsibilities
- Select providers for review based on historical results and dollar volume
- Schedule and conduct claim reviews using medical charts, medical notes, itemized bills, and provider contracts
- Verify claim dollar amounts in the claims system and request payments for overpayments
- Identify aberrant billing patterns and detect potential abuse
- Conduct exit interviews and draft reports, policies, and educational materials
Technical Overview
The technical scope centers on healthcare claims audit workflows: selecting providers and claims based on historical results and dollar volume, performing chart and contract reviews, verifying claim amounts in a claims system, and documenting findings for reconciliation through requested payments.
Ideal Candidate
The ideal candidate is a senior provider auditor with 3+ years of equivalent experience in healthcare audit review. They are experienced reviewing medical charts, medical notes, itemized bills, and provider contracts to verify claims accuracy against reimbursement policies, detect billing aberrations, and produce findings reports.
Must-Have Skills
on-site reviews of medical chartsreview itemized bills and provider contracts to ensure claim is paid in accordance with contract and provider reimbursement policiesverify dollar amount on claim is correct in claims systemwrite report of findings and request payments for any overpaymentsidentify aberrant patterns of billing and detect potential abuseconduct exit interview with provider management teamdraft department policies and procedures
Nice-to-Have Skills
Professional Coder certification
Tools & Platforms
claims system
Required Skills
medical chart reviewmedical notes reviewitemized billsprovider contractsprovider reimbursement policiesclaims system verificationoverpayment recoveryexit interviewsidentify aberrant billing patternsdetect potential abusementoring provider auditordraft policies and procedures
Hard Skills
on-site reviews of medical chartsmedical chart reviewmedical notes reviewreview of itemized billsprovider contract reviewclaim payment reviewverifying dollar amount on claimclaims system verificationwriting review findings reportrequesting payments for overpaymentsdetecting potential abuseidentifying aberrant billing patternsselecting providers for review based on historical resultsanalyzing data to select claims to be reviewedconducting exit interviews with provider managementmentoring and training provider auditordrafting department policies and proceduresdrafting educational materialsworking on task forces and committeesprovider reimbursement policiesindustry standards
Soft Skills
stakeholder managementcommunicationpresentation skills (exit interview presentations)mentoringcross-functional collaborationanalytical thinkingattention to detail
Certifications
Preferred
Professional Coder
Keywords for Your Resume
Provider Auditor SeniorProvider AuditorAuditon-site reviewsmedical chartsmedical notesitemized billsproviders contractsprovider reimbursement policiesindustry standardsclaims systemverify dollar amountoverpaymentsexit interviewaberrant patterns of billingdetect potential abusementors and trains Provider Auditordepartment policies and procedureseducational materialstask forces and committeesdollar volume of providernetwork management inputselects providers to be reviewed
Deal Breakers
Must be able to meet hybrid expectation of being in-office 1-2 days per week at one of the listed locations unless commuting distance criteria is met or an accommodation is granted
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