Senior Provider Audit Specialist

Capital Blue Cross

. Lead end-to-end audits of provider charge masters, billing practices, and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements .

Posted 9/20/2025full-timeRemote • Pennsylvania • 🇺🇸 United StatesSenior💰 $72,870 - $137,290 per yearWebsite

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

Lead end-to-end audits of provider charge masters, billing practices, and associated claims to evaluate billing accuracy, rate structures, and adherence to contractual and regulatory requirements
Design and enhance audit frameworks, models, dashboards, and templates that standardize audit execution and support enterprise provider audit functions
Evaluate audit findings and exercise professional judgement to determine materiality, recovery potential and recommended resolution strategies
Lead or support provider discussions related to audit findings, including explaining methodologies, defending determinations, and recommending corrective actions or process improvements
Maintain current knowledge of CMS guidelines, payer policies, and healthcare billing standards
Recommend process improvements, charge containment strategies, and policy changes to ensure appropriate billing and reimbursement practices
Drive proactive analytical studies to assess changes in provider billing patterns, charge description masters and other variable reimbursement provisions
Provide technical guidance, mentoring, and quality oversight to Provider Audit Specialists

Requirements

What you’ll need

Minimum of five (5) years of progressive experience conducting provider billing, reimbursement, or payment integrity audits
Expertise in CPT/HCPCS coding, CMS billing guidelines, and provider reimbursement methodologies
Advanced experience with Microsoft Office Suite products (Access, Excel, Word, PowerPoint), SAS, SQL, Power BI, or other software used for analytic, reporting, and data visualization functions
Bachelor's degree in healthcare administration, Health Information Management, Accounting, or related field
Preferred certifications: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA)

Benefits

Comp & perks

Medical, Dental & Vision coverage
Retirement Plan
Generous time off including Paid Time Off
Holidays
Volunteer time off
Incentive Plan
Tuition Reimbursement
Flexible environment

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

provider billing auditsreimbursement auditspayment integrity auditsCPT codingHCPCS codingCMS billing guidelinesprovider reimbursement methodologiesdata analysisaudit frameworkscharge containment strategies

Soft Skills

leadershipprofessional judgementcommunicationmentoringproblem-solvinganalytical thinkingprocess improvementcollaborationattention to detailstrategic thinking

Certifications

Certified Professional Coder (CPC)Certified Professional Medical Auditor (CPMA)