Auditor (intermediate), Zero Balance / Senior Auditor (Advanced), Zero Balance (
About Us:
Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals.
We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.
JOB SUMMARY:
Healthcare Auditors develop contract models for analysis and identify potential insurance reimbursement issues through extensive review of hospital claim data and related documentation. Auditors contribute to the organization's knowledge base by researching reimbursement risk areas, reviewing data and processes for quality control, identifying opportunities for improvement, and providing recommendations that support client reimbursement recovery and operational excellence. We are currently looking for 1 intermediate and 1 advance Auditor with knowledge of Zero Balance Accounts to join our team.
This is a remote position
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.
This is a remote position.
Essential Duties and Responsibilities
- Create and update audit plans, including identifying potential risk areas within hospital-payer contracts and outlining methodologies for identifying those risks within claims data.
- Review insurance payments and supporting documentation, including provider contracts, medical records, payer policies, and federal or state regulations, to determine payment accuracy and identify reimbursement opportunities.
- Research, analyze, and summarize underpayment issues, financial impacts, reimbursement trends, and recommended actions.
- Identify contractual and clinical reimbursement risk areas across commercial and government payors, including Medicare, Medicaid, coordination of benefits, workers' compensation, and other specialized audit areas.
- Develop specifications and procedures to identify and troubleshoot contractual, coding, and administrative underpayment risks using Excel, Access, SQL, and other analytical tools.
- Conduct reviews of zero-balance hospital accounts to identify underpaid inpatient and outpatient claims.
- Model reimbursement methodologies and create or maintain pricing documents used to calculate expected payments, including percent of charge, per diem, MS-DRG, outlier/stop-loss, implants, drugs, Medicare, Medicaid, outpatient reimbursement methodologies, and other payment structures.
- Work collaboratively with data analysts and project teams to develop, validate, and enhance pricing models and audit methodologies.
- Leverage technical tools and automation opportunities to improve audit efficiency and consistency.
- Present findings, processes, methodologies, and recommendations through clear documentation and reporting.
- Recommend improvements to internal processes, audit methodologies, and client contract administration processes.
- Research emerging reimbursement trends, regulatory changes, and payer practices and communicate findings to internal stakeholders.
- Other duties as assigned.
Additional Senior-Level Responsibilities
In addition to the responsibilities listed above, Senior Auditors may:
- Independently lead complex audit projects and reimbursement investigations.
- Identify new audit opportunities and reimbursement risk areas.
- Serve as a subject matter expert on contract interpretation, reimbur